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The Weekly Waluation of the Weasel Words of Woo #6

An Apology

OK, I plead guilty to being a week late in this crucial series—one that has the vast readership of SBM sitting on the edge of its collective seat! Proof of that assertion, of course, is found in the overwhelming number of Waluations submitted for the passage offered in the W^5/2 #5: Six. Another apology, if only a minor one: when I wrote, “the ‘plot’ of that paragraph has a little something that’s different from the usual fare,” I was probably wrong. I thought, somehow, that the passage had promoted the idea that “the integrative medicine movement” might offer physicians an antidote to “the limitations managed care has placed on their earning capacity.” Upon rereading the passage, I realized that it had not explicitly made that assertion.

A Wawiety of Cweative Waluations

Your faithful judge was faced with a difficult task this time: there were several clever and thoughtful Waluations, but they were so different from one another, stylistically, that choosing among them became an Apple ’n’ Orange typa thing. Let’s get to it: (more…)

Posted in: Humor

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We Have to Draw the Line Somewhere

Passive acceptance of Alternative Medicine has eroded the quality of medical care in this country. With the DSHEA of 1994 and political correctness, we have lost the reverence afforded to us in times past. Our professional knowledge is called into question as our standards deteriorate. There no longer exists a line separating proven fact from speculation. There is no border separating reality from mythology. Our colleagues treat with antibiotics and homeopathy. With beta-blockers and energy fields. Qi and narcotics.

For many years, it has seemed that I was nearly alone in my skepticism. Anytime I would bring up an alternative medicine topic, (in reality: criticize it) others in my field would have a ho-hum reaction to it. It was politically incorrect to rant about the growth of alternative medicine, the growing use of herbs, and how something should be done about it. We family and internal medicine doctors are a generally easy lot to live with. We accept patients and their faults, and it is hard to suddenly become judgmental when it comes to our colleagues. I had no idea as a resident that there was so much woo in Colorado. Specifically, I had no idea how much there was at my academic institution. This was in the late 80s, early 90s! Oh my, how things have changed, and not for the better.

I was a naïve resident in 1990, when a nurse practitioner at my residency called me about one of my patients. She wanted to help a 20 year old woman stop smoking by… wait for it….Therapeutic Touch. I was post call, and had trusted this NP as she had been with the residency for many years. I said “yes, go ahead,” not knowing what exactly it entailed. When I did have time to look into it, I was appalled. I was guilty by association. The patient never returned to me, and I don’t blame her. She must have thought I believed in magic. It turns out that the School of Nursing at the University of Colorado had to be called out by the Rocky Mountain Skeptics on their aggressive promotion and advocacy of Therapeutic Touch.

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Posted in: Politics and Regulation, Science and Medicine

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The Real ID

Stein: When we just saw that man, I think it was Mr. [PZ] Myers, talking about how great scientists were, I was thinking to myself the last time any of my relatives saw scientists telling them what to do they were telling them to go to the showers to get gassed.Stein (speaking about the Holocaust): …that was horrifying beyond words, and that’s where science — in my opinion, this is just an opinion — that’s where science leads you.Crouch: That’s right.

Stein: … Love of God and compassion and empathy leads you to a very glorious place, and science leads you to killing people.

I am a full time Infectious Disease physician. In the short hand of the medical field, I am an ID doc. Recently, saying I do ID is kind of like having last name like Himmler. No relation, but a vague discomfiture that I might be misrecognized as something else.

My ID, the real ID, along with medicine, is a branch of science (I always hear Mangus Pyke in the Thomas Dolby song when I type the word) with a long history, of, well, saving lives. Lots of lives. Millions and millions of lives. And relieving suffering. The simplest of things have been responsible for the long and reasonably healthy lives we get to have here in the industrialized world.

The Science-Based Medicine Blog deals with what Merlin Mann refers to as first world problems. The fine points of botanicals and prostatism or whether the placebo effect is the cause of the response to acupuncture. Interesting though these topics can be to some, when it comes to the overall health of most of us in the first world the main triumphs of science (Or is Ducks Breath I hear? “I have a masters degree in Science”) occurred over a century or two ago. The science of 200 years ago, by the standards of today, was simple, with simple results, but lead to remarkable advances in longevity and health.

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Posted in: Science and the Media

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Changing the Rules of Evidence

My daughter, Julia, loves to play games and has a bit of a competitive streak. She can make any activity into a game and is adept at making up rules on the spot. When she was younger, like most children, she had a tendency to add to or change the rules on the fly – usually to ensure a favorable outcome for herself. “Oh, Daddy, I forgot to mention that the ball can bounce once and that still counts.”

It was an opportunity for me to gently teach her that in order for rules to work everyone has to know what they are ahead of time and you can’t change them after the fact. Her smile told me that even at five she intuitively knew this already – that changing or making up new rules was not fair. What I was really teaching her was that she wasn’t going to get away with it with me, and by extension that it is socially unacceptable to mess with the rules to suit oneself.

Adults are really no different than children in our basic emotional makeup. We all want to change the rules to suit our own needs. The true difference is that as we mature we become more socially sophisticated; we become more subtle in our manipulations, and we develop the capacity to rationalize our wants and desires. We also learn that we are playing a bigger game – the social game. So we adhere to the rules of fairness, even if it means losing a competition, because we want to succeed at the more important game of socialization. (I’m not making any moral or ethical judgments here, just observing human behavior.)

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Posted in: Clinical Trials, Science and Medicine

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Reading Medical Literature with a Critical Eye

A long time ago I read a study about what makes a good doctor. Some things you might think were important, like grades in medical school, were irrelevant. What correlated the best was the number of medical journals a doctor read. I don’t know whether that means good doctors read more journals or reading more journals makes a better doctor.

One thing I do know is that most of us could learn better journal-reading skills. When I was a busy clinician, I did what I suspect many busy clinicians do: I let the journals pile up for a while, then tackled a stack when I got motivated. I would skim the table of contents to pick out articles that I wanted to read, then I would read the abstracts of those articles. If the abstract interested me, I would read the discussion section of the article. If I was still interested, I might go back and read the entire article. But until after I retired, I never really developed the skills to evaluate the quality of the study.

I knew enough not to jump on the bandwagon the first time something was reported, because I had seen promising treatments bite the dust with further testing. But I really wasn’t aware of all the things that can go wrong in a study, and I didn’t know what to look for to decide if the results were really credible. I’m not an academic; I thought the authors knew a lot more than I did, and I trusted them to a degree that was not warranted. (more…)

Posted in: Pharmaceuticals, Science and Medicine

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Monkey business in autism research

NOTE: I had originally planned on posting Part II of a series on cancer screening. However, something came up on Friday that, in my estimation, requires a timely response. I should also inform readers that, because next Monday is a holiday here in the U.S., I haven’t yet decided whether I will be doing a post next week or not. Stay tuned and check back.

I get e-mail.

Sometimes the e-mail is supportive. Other times, as you might imagine, given some of my posts, it is anything but. On Friday afternoon, I happened to notice an e-mail from an “admirer” of mine that said something like this:

You are a complete jack-ass.

- Generation Rescue

Appended to the e-mail was a link to this article on the Age of Autism blog.

Generation Rescue, as you may recall, is an organization that promotes the idea that vaccines cause autism, and this e-mail almost certainly came from the founder and head of GR, a man named J.B. Handley. In case you don’t know who he is, Handley is a man who is, even by the standards of antivaccinationists, incredibly boorish and possessed of a bull-in-a-china shop manner that alienates even some potentially sympathetic people, although parents who believe that vaccines cause autism seem to love him. He is also quite–shall we say?–flexible in his notions of how vaccines cause autism. Until about a year ago, the Generation website stated unequivocally:

Generation Rescue believes that childhood neurological disorders such as autism, Asperger’s, ADHD/ADD, speech delay, sensory integration disorder, and many other developmental delays are all misdiagnoses for mercury poisoning.

About a year ago, it changed to:

We believe these neurological disorders (“NDs”) are environmental illnesses caused by an overload of heavy metals, live viruses, and bacteria. Proper treatment of our children, known as “biomedical intervention”, is leading to recovery for thousands.

The cause of this epidemic of NDs is extremely controversial. We believe the primary causes include the tripling of vaccines given to children in the last 15 years (mercury, aluminum and live viruses); maternal toxic load and prenatal vaccines; heavy metals like mercury in our air, water, and food; and the overuse of antibiotics.

The kind interpretation is that GR was changing its hypothesis given that the data being published consistently and strongly refuted the myth that mercury in vaccines somehow cause autism. In reality, though, it’s fairly clear that GR was pivoting effortlessly to a hypothesis that not only was nearly completely unfalsifiable but also allowed GR to continue to blame vaccines for autism, which is what it’s really about. More recently, as I have pointed out before, antivaccinationist rhetoric has also pivoted even further and equally as effortlessly to blame unspecified “toxins” or “combinations of toxins” in vaccines. Be that as it may, having felt the love, I have to admit that Mr. Handley sure does know how to charm a guy. When he draws my attention to some abstracts so politely, abstracts that he clearly considers to be very important evidence, how can I refuse to take a look? After all, Mr. Handley himself apparently very much wanted to point me in the direction of these three abstracts, and it would be downright churlish of me to deny him and refuse to look at the studies with as open a mind as possible.
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Posted in: Basic Science, Medical Academia, Neuroscience/Mental Health, Politics and Regulation, Public Health, Vaccines

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“Chelation Therapy”: Another Unethical “CAM” Trial Sponsored by Taxpayers

Please forgive the promotion of our own work and the facile evasion of a full-length blog, but two of your faithful bloggers are co-authors of an article published this week:

Why the NIH Trial to Assess Chelation Therapy (TACT) Should Be Abandoned

Kimball C. Atwood IV, MD; Elizabeth Woeckner, AB, MA; Robert S. Baratz, MD, DDS, PhD; Wallace I. Sampson, MD

Medscape J Med.  2008;10(5):115.  ©2008 Medscape

Posted 05/13/2008

Available here.

You may be asked to “register”; don’t worry, it’s free. The article is very long, but the Introduction, Executive SummaryDiscussion, and Conclusion are reasonably succinct and make the important points. Readers who want to learn more details, who want to see more evidence for our assertions, or who are compelled by an odd fascination with crackpotism (my own weakness) will want to read more. Here is a small sample:

Abstract

The National Institutes of Health (NIH) Trial to Assess Chelation Therapy (TACT) was begun in 2003 and is expected to be completed in 2009. It is a trial of office-based, intravenous disodium ethylene-diamine-tetra-acetic acid (Na2EDTA) as a treatment for coronary artery disease (CAD). A few case series in the 1950s and early 1960s had found Na2EDTA to be ineffective for CAD or peripheral vascular disease (PVD). Nevertheless, a few hundred physicians, almost all of whom advocate other dubious treatments, continued to peddle chelation as an office treatment. They claim that chelation dramatically improves symptoms and prolongs life in 80% to 90% of patients. In response, academics performed 4 controlled trials during the 1990s. None favored chelation, but chelationists repudiated those findings.

We have investigated the method and the trial. We present our findings in 4 parts: history, origin and nature of the TACT, state of the evidence, and risks. We present evidence that chelationists and their organization, the American College for Advancement in Medicine, used political connections to pressure the NIH to fund the TACT. The TACT protocols justified the trial by misrepresenting case series and by ignoring evidence of risks. The trial employs nearly 100 unfit co-investigators. It conflates disodium EDTA and another, somewhat safer drug. It lacks precautions necessary to minimize risks. The consent form reflects those shortcomings and fails to disclose apparent proprietary interests. The trial’s outcome will be unreliable and almost certainly equivocal, thus defeating its stated purpose.

We conclude that the TACT is unethical, dangerous, pointless, and wasteful. It should be abandoned.

Readers of my postings on SBM will find more discussion (and abundant evidence) of familiar material: ethical breaches resulting from political incursions into science; the pitfalls, both scientific and ethical, of ignoring prior probability; a Dirty Secret of the Extraordinary Popular Delusion that is “CAM,” that much of what masquerades as sober research or the practice of “integrative medicine” was spawned by Laetrile; and widespread dishonesty in “academic CAM.”

Medscape Journal of Medicine invites readers to post comments or to send private letters to the editor for potential publication (and replies by yours truly, in this case). If you are so moved, you might consider posting comments in duplicate, both there and here on SBM, for the benefit of our select readership.

Posted in: Clinical Trials, Health Fraud, Medical Ethics, Politics and Regulation

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The Trojan Horses of Education

Last time I described what I could find about the “Quiet Revolution” plan for medicine through the eyes and minds of the Bravewell Collaborative and Christy Mack, wife of the multi-millionaire or billionaire CEO John Mack. The idea seemed two-pronged; “humanize” physicians and medicine generally, and integrate folkway, sectarian and “alternative” methods into the system. What bothered me more, having become inured to patient philandering with quackery, was the brazen attempt to re-educate physicians and indoctrinate students into the political and social views of wealthy idealists. The entry below, one might conclude, has little to do with medical quackery and pseudoscience, but I beg your indulgence for this series as I attempt to connect dots between the stalls of the seemingly unrelated steeds of political indoctrination in universities and the proposed med school re-education camps of Bravewell. For several years a controversy has roiled at the University of Delaware over a program of educational activities for the dorms called Residence Life. The program structures student time with a number of usual activities – games, talks, discussion groups – but the content of the discussion groups and interpersonal counseling upset some students, who complained to an off-campus conservative organization, and got to the attention of faculty, which pressured the administration to stop the program last fall.

To outsiders such as we, the program looked like a feel-good, beneficent guidance tools. To the complaining students and critics the discussions seemed more like indoctrination groups, with political agendas taking on disguised roles as helpful guidance for student angst. Students complained about invasion of their privacy through group and leader pressures, and the faculty saw indoctrination and invasion of their educational duties (turf) by student counselors bearing ideological messages with little qualification.

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Posted in: Medical Academia, Politics and Regulation

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Canada Bill C-51 – Regulating Natural Health Products

In Canada a new bill has been proposed, Bill C-51, that would make changes to the Food and Drug Act – the body of laws by which the Canadian federal government regulates food and health products in Canada. This is the equivalent of the Food and Drug Administration (FDA) in the US. It seems that Canada, like the US, is struggling to deal with a burgeoning industry of “natural health products” that are minimally regulated.

The new bill will increase government oversight of natural health products (NHP) for the purpose of ensuring higher quality standards for products and accuracy in the claims that are made for them. Proponents of the bill claim that it will serve to improve consumer protection. But the NHP industry is not happy with the increased oversight the bill would bring. Their hysterical reaction to the proposed bill is very revealing about the propaganda and deception used by the NHP industry.

This history of NHP regulation in Canada also reveals the two primary strategies by which the promoters of unscientific medicine and health products seek to advance their business. On the one hand they seek licensure, certification, and other formal recognition by the government in order to bolster their legitimacy with the public and also to keep competition at bay. When seeking such things they argue that licensure etc. will give the government the opportunity to regulate the industry and ensure quality control. They therefore take the position of consumer protection.

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Posted in: Herbs & Supplements, Politics and Regulation

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The “Art” of Clinical Decision-Making

Much nonsense has been written about the “art” of medicine. All too often, it amounts to a rationalization for doctors doing what they want to do instead of following the evidence. Medicine is not an art like painting. Neither is it a science like physics. It’s an applied science. Since patients are not all identical, it can be very tricky to decide how to apply the science to the individual.

The New England Journal of Medicine periodically runs a feature called “Clinical Decisions.” They present a case history, then they present 2 or 3 expert opinions on how to manage the case. They stress that none of the options can be considered either correct or incorrect. They allow readers to “vote” as well as to submit comments about why they voted that way. It is understood that the voting is only for interest and to stimulate discussion: it does not result in a consensus.

In April 2008 the topic was the management of carotid artery stenosis. The patient is a 67 year old man who has no symptoms but who is found to have a narrowing of 70-80% in one carotid artery and 20% in the other, putting him at increased risk for stroke. He has other risk factors for cardiovascular disease: hyperlipidemia, hypertension, and overweight. The 3 options are medical management, stent placement, and carotid endarterectomy. (more…)

Posted in: Science and Medicine

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