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The ultimate in “integrative medicine”: Integrating the unscientific into the medical school curriculum

For the second week in a row I find myself throwing out the original post that I had planned on doing in favor of a different topic. The reason this week is, quite simply, having read Dr. Atwood’s excellent two part post Misleading Language: The Common Currency of “CAM” Characterizations (Part I; Part II). I don’t at this time intend to expand on what Dr. Atwood said, although I may do so at one future time. What caught my attention in his lengthy deconstruction was his segment on the “woo-ification” of health care, which very much echoed my post a while back in which I lamented the creeping infiltration of non-science-based modalities into academic medical centers, as well as the credulous teaching of such modalities in medical schools. What I wanted to explore was just how far this might go and what the end result might be. It turns out that we are already witnessing an experiment in just such a thing.

About a year and a half ago, I first became aware of just how far this infiltration of unscientific “medicine” has infiltrated academia when I saw this brochure published by the Georgetown University School of Medicine. If you’re scientifically inclined, as I am, it ought to make you shudder. Reading this brochure, I truly have to worry whether woo really is the future of American medicine, as has been suggested in some quarters. Certainly, if other medical schools start following Georgetown’s lead, it will be. Not content to offer so-called complementary and alternative medicine (“CAM”) modalities as part of electives that interested students can take if they are so inclined, Georgetown is taking the next logical step that I feared: It’s dedicating significant educational resources and time to teaching “CAM” in its mandatory general medical curriculum, where every student has to learn it:
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Posted in: Medical Academia, Science and Medicine

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Misleading Language: the Common Currency of “CAM” Characterizations Part II

Background

I promised readers the “Advanced Course” for this week, which undoubtedly has you shaking in your boots. Fear not: you’ve already had a taste of advanced, subtle, misleading “CAM” language, and most of you probably “got” it. That was R. Barker Bausell’s analysis of how homeopathy is “hypothesized to work.” In the interest of civility, let me reiterate that I don’t think of Bausell as a horrible person or an ignorant boor for having written that statement. Rather, I think of him as having been so steeped in the de rigueur “CAM” language distortions of the 1990s that he is largely unaware of their insidious power. I suspect too that he, like most of us who grew up when schools no longer stressed the rigors of English composition, has an underdeveloped sense of the relation between the craft of writing and the integrity of its content. That doesn’t excuse him from writing honest prose, of course.

Last week’s post cited blatant language distortions of “CAM”—euphemisms, slogans, and outright falsehoods—and some that were more subtle: question-begging, misrepresentation, and derogation. It would require a semester’s worth of seminars to delve into the overlapping categories of misleading “CAM” language, but here we can consider a few. Then, perhaps, we’ll engage in an amusing diversion—more about that at the end of this post. (more…)

Posted in: Medical Academia, Medical Ethics, Science and Medicine

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Persistence of Memory

I have steadily endeavored to keep my mind free so as to give up any hypothesis, however much beloved (and I cannot resist forming one on every subject), as soon as the facts are shown to be opposed to it.
— Charles R. Darwin

I’m getting old: 50, almost 51, and that’s over 350 in dog years. As a result of my advancing age there are things I do not get: tattoo’s, hip hop, visible undergarments, and those rectangular, square plastic glasses that seem so popular and look hideous on everyone. It gets harder to change.

I have been able to stick MD after my name for almost a quarter century now (175 dog years for those keeping track), and it does give a sense of perspective to the ebb and flow of medical therapies. Medicine for the last hundred years has been all about change. Dogma from last century is nonsense this century, all due to that damn science. It gets so tiresome having to learn something new.

Last month’s New England Journal of Medicine was another in a seemingly endless series of plus ça change, plus c’est la même chose moments.4 They published the results of the CORTICUS study, a trial that looked at Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration, was conducted by Irving Kirsch and colleagues, who reviewed clinical trials of six antidepressants (fluoxetine, venlafaxine, nefazodone, paroxetine, sertraline, and citalopram). They looked at all studies submitted to the FDA prior to approval, whether published or unpublished. They found:

Drug–placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients. The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication.

The press has largely reported this study as showing that “antidepressants don’t work” but the full story is more complex. This analysis certainly has important implications for how we should view the body of evidence for these antidepressants. It also illuminates the possible role of publication bias in the body of scientific literature – something that has far ranging implications for science-based medicine.

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Posted in: Clinical Trials, Neuroscience/Mental Health, Pharmaceuticals, Science and Medicine

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Science and Chiropractic

In the comments to a previous blog entry, a chiropractor made the following statements:

1. Chiropractic is a science.
2. Chiropractic is based on neurology, anatomy and physiology.
3. Chiropractors are doctors of the nervous system.
4. Chiropractic improves health and quality of life.

I offered to write a blog entry on the “science” of chiropractic, and I asked him, both in the comments section and by personal e-mail, to educate me first by providing me whatever evidence he could find to support those claims. I never heard back from him, so I was left to do my own research as best I could. Here’s what I found.

Is chiropractic a science? No.

In 1895, a magnetic healer named D. D. Palmer adjusted a deaf man’s back and allegedly restored his hearing. Generalizing from this one case, he reasoned that “A subluxated vertebra… is the cause of 95 percent of all diseases. …The other five percent is caused by displaced joints other than those of the vertebral column” (more…)

Posted in: Chiropractic

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The Hannah Poling case and the rebranding of autism by antivaccinationists as a mitochondrial disorder

Regular readers of this blog may have noticed that I seem to have taken on the role of the primary vaccine blogger of this little group of bloggers trying desperately to hold the forces of pseudoscience and magical thinking at bay in the face of powerful forces trying to “integrate” prescientific belief systems with science- and evidence-based medicine, a process that would be unthinkable in just about any other field of applied science, such as aeronautics or the physics used in engineering, just as creationists try to “integrate” religion with biology. Although I do have a strong interest in the antivaccination movement in general and the claim that vaccines, or the mercury in the thimerosal preservatives that was in many childhood vaccines in the U.S. until late 2001 or early 2002 (when they were taken out) are a major cause or contributor to autism, such had not been my intention. When I started here on SBM, I had intended to be a lot more diverse. Indeed, I had even had another topic entirely in mind for this week’s post, but, as happens far too often, news events have overtaken me in the form of a story that was widely reported at the end of last week. It was all over the media on Thursday evening and Friday, showing up on CNN, Larry King Live, the New York Times, and NPR. It happens to be the story of a girl from Georgia named Hannah Poling whose case before the Vaccine Injury Compensation Program (VICP), which had originally part of a much larger proceeding known as the Autism Omnibus in which nearly 5,000 parents are petitioning the VICP for compensation based on the claim that their children’s autism were caused by vaccines, was settled by the government. This settlement was based on the observation that Poling had a rare genetic mitochondrial disease that may have been exacerbated by a series of vaccines that she had, after which, among many other problems, Hannah regressed and developed some autism-like symptoms and then months later a seizure disorder. Instantly, it was being trumpeted all over the Internet, blogosphere, and media that the government had “admitted” that vaccines cause autism. One particularly excitable antivaccinationist named Kent Heckenlively (whom we’ve met before), even went so far as to foreshadow the propaganda blitz that was to come as he wrote on the antivaccine blog Age of Autism a full week before this news blitz began:

It’s official.  The sky has fallen.  The fat lady has sung.  Pigs are flying.

[...]

In a settlement, the settling party tries to admit as little as possible.  It’s like what I imagine the settlement claim against Bill Clinton in the Paula Jones case must look like.  Nowhere in the document does he admit to dropping his pants in a hotel room and asking her to kiss it.  It likely says something along the lines of he concedes they were in a hotel room together, they were alone, and something happened which formed the basis of her law suit.

But we all know what happened there.  And we know what this settlement means.

The government just dropped its pants.

One thing this shows us is just how the blogosphere can be bubbling with information that lets one predict a public relations blitz like this. The mainstream press seemed to have been totally blindsided by this story, but if reporters had only been checking the right blogs, they would have known about it a full week before, if not longer. In any case, since Thursday, there has been a very well orchestrated public relations campaign to frame this settlement as the government “admitting” that vaccines cause autism. It’s not, as I will try to explain, but framing it that ways has thus far been a very effective PR strategy for antivaccinationists. In my nearly three years of following this topic, I thought that I had never seen anything like it before.

But I had.

This case is nothing more than a demonstration that everything old is new again and that, no matter what the science says, it’s always all about the vaccines, the claims of antivaccinationists otherwise notwithstanding, as I will now show. What we are seeing now, as we did a few years ago, is the rebranding of autism as a condition in order to serve the purposes of the antivaccination movement.
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Posted in: Public Health, Science and Medicine, Science and the Media, Vaccines

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Misleading Language: the Common Currency of “CAM” Characterizations. Part I

The Best Policy

From time to time I have been reiterating that correct use of the language has much to do with logic; I should add that it entails also honesty. I use the word “honesty” in its broadest sense…

Concision is honesty, honesty concision—that’s one thing you need to know.

—John Simon. Paradigms Lost: Reflections on Literacy and its Decline. New York, NY: Clarkson N. Potter, Inc.;1980. pp. 48, 52

Prologue

In 1983, a naturopath in Alberta inserted balloons into the nostrils of a 20 month-old girl and inflated them. The child died of asphyxiation. Subsequently, a judge described the treatment—dubbed “bilateral nasal specific” by the chiropractor who had invented it—as “outright quackery.” [1] Fast-forward 15 years: a woman presented to the otolaryngology clinic at the University of Washington in Seattle “complaining of severe midface pain and epistaxis” (nosebleed). She had suffered nasal septal fractures caused by a similar treatment, by then renamed “NeuroCranial Restructuring” (NCR). In their case report, the surgeons who had treated the woman at U. Wash discussed the claims of NCR and explained that the relevant anatomy predicts that it is implausible and risky. They also reported that it is expensive: “$2000 to $4800 for a standard course (of 4 treatments).” They concluded:

This case report of a complication after a CAM procedure called NCR highlights the wide range of treatment options available to patients. It is important for otolaryngologists to be aware of the spectrum of CAM therapies that patients may pursue and be aware of potential complications from these procedures.

An accompanying editorial used similar language.

How is it that in 1983 a judge could offer a concise summary of the essence of such a method, whereas scarcely a generation later 5 highly-trained medical doctors, even after presenting the sordid facts, could only obscure it with bland euphemism? (more…)

Posted in: Health Fraud, Medical Academia, Medical Ethics, Politics and Regulation

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RCT Plausibility Scale

RCT Plausibility Scale

After a few intro paragraphs, I want to present a scale of probability to estimate a value of a “prior” to plug into the formula for obtaining a Bayes Factor. The scale can help to estimate a value, but will still rely on an estimate, the non-quantitative element in Bayesian simulations. However, the checklist may at least provide some objective bases on which to hang a value, and that value would actually make a semi-quantitative statement of its own. Although that value would retain some subjective quality, it would at least be backed by known quantities and laws of nature.

Begging your patience again, I became aware of this problem in 1999 when asked to moderate an online (BioMednet.com) debate on “CAM” among 4 physicians. My role soon morphed into participant-debater when I could not get all to agree on what I thought was obvious common ground to proceed with the discussion – that 1) concepts that violate scientific laws do not have to be subjected to clinical trial (RCT) and that trial results had to be interpreted in light of previous knowledge; and 2) clinical trials could not constitute adequate evidence in the absence of plausibility because their results were too varied and inconsistent. The matter was p-recipitated by systematic reviews (SRs) showing efficacy of acupuncture in back pain. I was truly surprised when one of the participants (Dr. Edzard Ernst) assured me that indeed, RCTs were now the gold standard for efficacy. The debate went downhill from there.

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Posted in: Clinical Trials, Science and Medicine

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Science-Based Nutrition

One of the most successful propaganda campaigns within health care in the last few decades has been the re-branding of nutrition as “alternative” or out of the mainstream of scientific medicine. I have marveled at how successful this campaign has been, despite all the historical evidence to the contrary. I suppose this is partly a manifestation of the public’s short-term memory, but it also seems to reflect basic psychology.

Some History

There is evidence that most ancient cultures recognized the importance of diet in health. The Greeks recognized both the benefits of a varied diet and the negative health consequences of obesity, for example. But knowledge of nutrition was limited to these broad observations and was mixed with superstition and cultural beliefs.

The science of nutrition probably dates back to 1614 when scurvy (the disease that results from vitamin C deficiency) was first recognized as a dietary deficiency, one that could be cured by eating fresh fruits and vegetables. In 1747 Lind conducted what might be the first clinical trial – systematically comparing various diets for the treatment of scurvy and finding that citrus fruits were the key to treatment.

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Posted in: Herbs & Supplements, Nutrition, Public Health, Science and Medicine

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Ultrasound Screening: Misleading the Public

There is a new industry offering preventive health screening services direct to the public. A few years ago it was common to see ads for whole body CT scan screening at free-standing CT centers. That fad sort of faded away after numerous organizations pointed out that there was considerable radiation involved and the dangers outweighed any potential benefits.

Now what I most commonly see are ads for ultrasound screening. In fact, I am sick and tired of finding them in my mailbox and between the pages of my local newspaper. Ultrasound is certainly safe, with no radiation exposure. It sounds like it might be a good idea, but it isn’t.

Life Line Screening advertises itself as “America’s leading provider of quality health screenings.” They offer “4 tests in less than 1 hour – tests that can save your life.” They travel around the country, setting up their equipment in community centers, churches, and YMCAs. For $129 you get ultrasounds of your carotid arteries, your abdominal aorta, your legs, and your heel bone. They mail you your results 21 days later. (more…)

Posted in: Health Fraud, Medical Ethics, Public Health

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