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Outcome Bias in Clinical Decision Making and the Assessment of Our Peers

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There are many mental pitfalls and logical stumbling blocks faced by healthcare professionals when attempting to untangle the complex web of patient history and physical exam findings. They can impede our ability to practice high quality medicine at every step in the process, interfering with our ability to establish an accurate diagnosis and to provide comfort or cure. And we are all susceptible, even the most intelligent and experienced among us. In fact, having more intelligence and experience may even enlarge our bias blind spots.

Steven Novella discussed the complexities of clinical decision making in early 2013, specifically tackling some of the more common ways that physicians can come to a faulty conclusion in the third installment of the series. One cognitive bias yet to be specifically addressed on the pages of Science-Based Medicine, and it is one that I encounter regularly in practice, is outcome bias. Simply put, outcome bias in medicine occurs when the assessment of the quality of a clinical decision, such as the ordering of a particular test or treatment, is affected by knowledge of the outcome of that decision. We are prone to assigning more positive significance to a decision when the outcome is positive, and we often react more harshly when the outcome is negative. This bias is particularly obvious when the result of a decision largely comes down to chance.

I see outcome bias rear its ugly head in two contexts for the most part: the Lucky Catch and the Bad Call.

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Posted in: Science and Medicine

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Homeopaths Threaten Public Health Selling Sugar Pills as Vaccine Alternatives

Alternative medicine is ascendant in Canada. From the dubious remedies that are now stocked by nearly every pharmacy, to the questionable “integrative” medicine at universities, there’s a serious move to embrace treatments and practices that are not backed by credible evidence. Canada’s support for alternative medicine, and for its “integration” into conventional health care is arguably is worse than many other countries. Canada’s drugs regulator, Health Canada, has approved hundreds of varieties of sugar pills and declared them to be “safe and effective” homeopathic remedies. Some provinces are even moving to regulate homeopaths as health professionals, just like physicians, nurses and pharmacists. Given the regulatory and legislative “veneer of legitimacy” that homeopathy is being granted, you can see how consumers might be led to believe that homeopathic remedies are effective, or that homeopaths are capable of providing a form of health care. The reality is far uglier, and the consequences may be tragic. Canadian homeopaths are putting the most vulnerable in society at risk by selling sugar pills to consumers, while telling them that they’re getting protection from communicable diseases. (more…)

Posted in: Homeopathy, Science and Medicine, Vaccines

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The Central Dogma of Alternative Medicine

Steve still happens to be galavanting about Australia, spreading science, skepticism, and, of course, science-based medicine Down Under. Given that, he has been unable to produce new content for today. Never one to let such an opportunity pass, I decided to take advantage in order to do a little shameless self promotion.

A week and a half ago, I gave a talk at Skepticon 7 in Springfield, MO, entitled “The Central Dogma of Alternative Medicine”. It has now been posted on YouTube:

Because some of the sound didn’t come through as well as one might hope, I’m also including the full video of Kim Tinkham that I used early in the talk to illustrate a point. I only used about two minutes’ worth of it, but here is the whole thing, in case you’re interested:

Let me know what you think! And don’t forget to donate to Skepticon, to keep the skeptical goodness coming next year and beyond.

Posted in: Cancer, Religion, Science and Medicine

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Vitamin D: To Screen or Not to Screen?

Vitamin D, the so-called sunshine vitamin, has generated a lot of attention in recent years. It has been claimed to benefit a wide variety of diseases, everything from cancer to multiple sclerosis. It is widely used along with calcium for bone health. It is added to milk and prenatal vitamins and is prescribed for breastfed babies. Some doctors are recommending everyone take it for prevention. Some CAM advocates are recommending it as a more natural way to prevent the flu than getting a flu shot.

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It has been touted as a panacea; Michael Holick even wrote a book titled The Vitamin D Solution: A 3-Step Strategy to Cure Our Most Common Health Problems. Christiane Northrup praised it, saying “This information can save your life. Really.” (Really? I’m skeptical, and her recommendation is not enough to make me want to read the book.) Then there’s Jeff Bowles’ book The Miraculous Results of Extremely High Doses of the Sunshine Hormone Vitamin D3 My Experiment With Huge Doses of D3 From 25,000 To 50,000 Iu A Day Over A 1 Year Period. That one’s not on my reading list either; the tolerable upper intake level is 4,000 IU a day.

It’s hard to avoid the hype and just examine the actual scientific evidence without any bias. The United States Preventive Services Task Force has tried to do just that. It recently evaluated screening for vitamin D deficiency and concluded that the current evidence is insufficient to recommend either for or against screening. Predictably, their announcement has already led to misunderstandings and protests.

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Posted in: Herbs & Supplements

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Selling “integrative oncology” as a monograph in JNCI

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Sometimes, it’s hard not to get the feeling that my fellow bloggers at Science-Based Medicine and I are trying to hold back the tide in terms the infiltration of pseudoscience and quackery into conventional medicine, a term I like to refer to as quackademic medicine. In most cases, this infiltration occurs under the rubric of “complementary and alternative medicine” (CAM), which these days is increasingly referred to as “integrative medicine,” the better to banish any impression of inferior status implied by the name “CAM” and replace it with the implication of a happy, harmonious “integration” of the “best of both worlds.” (As I like to point out, analogies to another “best of both worlds” are hard to resist.) Of course, as my good buddy Mark Crislip has put it, the passionate protestations of CAM advocates otherwise notwithstanding, integrating cow pie with apple pie doesn’t make the cow pie better. Rather, it makes the apple pie worse.

In any case, over the last three months, Steve Novella and I published a solid commentary in Trends in Molecular Medicine decrying the testing in randomized clinical trials of, in essence, magic, while I managed to score a commentary in Nature Reviews Cancer criticizing “integrative oncology.” Pretty good, right? What do I see this month in the Journal of the National Cancer Institute (or JNCI, as we like to call it)? An entire monograph devoted to a the topic, “The Role of Integrative Oncology for Cancer Survivorship”, touting integrative oncology, of course. And where did I find out about this monograph? I found out about it from Josephine Briggs, the director of the National Center for Complementary and Alternative Medicine (NCCAM) herself, on the NCCAM blog in a post entitled “The Evidence Base for Integrative Approaches to Cancer Care“, in which she touts her perspective piece in the JNCI issue entitled “Building the Evidence Base for Integrative Approaches to Care of Cancer Survivors.” In an introductory article, Jun J. Mao and Lorenzo Cohen of the Department of Family Medicine and Community Health, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania and the University of Texas M.D. Anderson Cancer Center, respectively, line up this monograph thusly:
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Posted in: Cancer, Clinical Trials, Medical Academia

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In the Spirit of Choosing Wisely

Oh, loneliness and cheeseburgers are a dangerous mix.
- Comic Book Guy

Same can be said of viral syndromes and Thanksgiving. My brain has been in an interferon-induced haze for the last week that is not lifting anytime soon. Tell me about the rabbits, George. But no excuses. I have been reading the works of Chuck Wendig over at Terrible Minds. (Really, really like the Miriam Black books). Writers write and finish what they start and only posers use excuses for not completing their work.

Recently I attended an excellent Grand Rounds on some of the reasons doctors do what they do. Partly it is habit. We learn to a certain way of practice early in our training and it carries on into practice and it is not always best practice. Patients also learn from us and have expectations on what diagnostics or treatments they should receive, and that too it is not always the best practice.

So to educate physicians and patients, the American Board of Internal Medicine (ABIM) started the Choosing Wisely initiative. (more…)

Posted in: Acupuncture, Chiropractic, Critical Thinking, Energy Medicine, Homeopathy, Science and Medicine

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Announcement: The Society for Science-Based Medicine is co-sponsoring NECSS

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Steve is off today, so I thought it would be a good idea to use this slot for a little shameless self-promotion (of Science-Based Medicine and the Society for Science-Based Medicine, of course).

The Northeast Conference on Science & Skepticism (April 9-12, 2015 in New York City) will be bigger than ever in 2015 with fabulous presenters, exciting panels, and engaging workshops.

We’re thrilled to announce that NECSS 2015 will be co-sponsored by the Society for Science-Based Medicine and will expand to include a third full day of programming! Friday’s schedule will be curated by the team at SfSBM and features content available exclusively at NECSS 2015. Saturday and Sunday schedules will once again feature the best of science and skepticism.

NECSS weekend also includes a special evening performance on Friday, two workshop tracks on Thursday for the early-birds, our popular “Drinking Skeptically” socializers, and more!

The full NECSS speaker line up will be announced shortly, but, as always, Rationally Speaking and the Skeptics’ Guide to the Universe will record live podcasts during the conference.

We have secured discounted room rates at the Hilton Fashion District, located one block from the main conference hall. These rates are available exclusively to NECSS attendees and we will be available shortly.

Conference registration will open in December, but you can like the NECSS Facebook page or follow us on Twitter for updates.

See you in April!

Posted in: Announcements, Science and Medicine

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Product B: Here We Go Again

“Telomeres shorten each time a cell divides. In most cells, the telomeres eventually reach a critical length when the cells stop proliferating and become senescent. But, in certain cells, like sperm and egg cells, the enzyme telomerase restores telomeres to the ends of chromosomes. This telomere lengthening insures that the cells can continue to safely divide and multiply. Investigators have shown that telomerase is activated in most immortal cancer cells, since telomeres do not shorten when cancer cells divide.” — National Institute of Aging

“Telomeres shorten each time a cell divides. In most cells, the telomeres eventually reach a critical length when the cells stop proliferating and become senescent. But, in certain cells, like sperm and egg cells, the enzyme telomerase restores telomeres to the ends of chromosomes. This telomere lengthening insures that the cells can continue to safely divide and multiply. Investigators have shown that telomerase is activated in most immortal cancer cells, since telomeres do not shorten when cancer cells divide.” — National Institute of Aging

New health products are constantly appearing on the market in such numbers that I can’t hope to keep up. Product B was new to me. I was introduced to it by a doctor who said a family member was “quite enthusiastic” about its potential to “lengthen telomeres and thereby address a myriad of health issues.” Of course, I immediately asked “What exactly are they claiming Product B does?” and “Do they have evidence that it actually does what they claim?” Their website didn’t provide satisfactory answers.

Product B is described as “a powerful blend of complex botanicals and vitamins uniquely designed to offer superior telomere support for youthful aging.” It is sold as part of a multilevel marketing (MLM) scheme. Because it is classified as a dietary supplement, FDA regulations only allow them to make “structure and function” claims, so the claims are deliberately nebulous. Basically, they seem to be saying that short telomeres are bad (they cause aging and disease), telomerase is good because it makes telomeres longer, and Product B is an effective way to increase telomerase; therefore Product B prevents disease and retards aging. But these assertions are questionable, and the website doesn’t offer any credible evidence of clinical efficacy for any single health issue, much less a myriad of them. Or any evidence of safety, for that matter.

Oh, good grief! It’s sold by the Isagenix company. Talk about déjà vu! Isagenix keeps coming back to haunt me; it even generated my favorite insult ever: “Dr. Harriet Hall is a refrigerator with a head.” You can read the three articles I wrote about Isagenix here, here, and here.

If I am a refrigerator, at least I try to be a fair one. I wasn’t going to reject the claims out of hand just because Isagenix made them. I spent quite a bit of time searching the Internet for information, and I even wrote the company to ask directly for their evidence. They didn’t bother to reply.

One thing puzzled me right off the bat. Was there a Product A that I had somehow missed? Why did they name this “Product B”? That doesn’t impress me as a savvy marketing choice. Couldn’t they have thought up something catchier like “Telomiracle”? I couldn’t help wondering what the B might stand for and my mind quickly associated the words bogus, blarney, business, baloney, bunk, bullshit, blunder, basura (Spanish for garbage), barbaridad (Spanish for stupid thing), and blague (French for joke). It made me think of second choice, as in “plan B.” What does it make you think of?

Pardon the digression. It makes no difference what they call it. “A rose by any other name…” All that matters is what it is and whether it works. (more…)

Posted in: Herbs & Supplements

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Selective pressures on alternative medicine

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(Editor’s note: I was away at Skepticon over the weekend, where I gave a talk entitled “The Central Dogma of Alternative Medicine”. (When the talk’s up on YouTube, I’ll provide a link, of course.) Because of all the fun and travel delays I didn’t get a chance to turn my slides and notes into a blog post yet. Also, I’m on vacation this week. However, this gives me the opportunity to resurrect a blog post from 2007 on my not-so-super-secret other blog, because I think the concept is interesting. I even use it in a slide that shows up in many of my talks (above). I’ve updated dead links and added some text to include relevant links to posts written since. Enjoy, and I’ll definitely be back next week with original material, if not sooner, given that there are others here who might have the temerity to take part or all of this week off.)

I wish I had thought of this one, but I didn’t. However, I never let a little thing like not having thought of an idea first to stop me from discussing it (even if Steve Novella’s also discussed it), and this particular idea is definitely worth expanding upon because (1) it’s interesting and (2) it combines two of my interests, alternative medicine and evolution. I agree with parts of the idea, but it’s not without its shortcomings. Indeed, I’d very much welcome any of the evolutionary biologists who read this blog to chime in with their own ideas.

A colleague of mine, Martin Rundkvist over at Aardvarchaeology, has proposed a rather fascinating idea regarding the evolution of alternative medicine in which he argues that alternative medicine evolves according to certain selective pressures. As you may or may not know, evolution is not just for biology, but has been proposed as a mechanism in cultural memes, for example. Since alternative medicine is a cultural phenomenon, it is not unreasonable to look at such non-evidence-based medicine and hypothesize what might be the selective pressures that shape its popularity and evolution. After all, if we’re going to discourage the use of non-evidence-based medicine or even quackery, it’s helpful to understand it. We already know that alt-med terminology has evolved considerably into the current preferred term, “integrative medicine.” (See also the image above and my blog posts on this evolution here and here.)
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Posted in: Basic Science, Evolution, Science and Medicine

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