Articles

Perpetual Motion: More on the Bravewell Report

I’m not here to convince people that we are right, although it would be nice if it turned out that way. I’m here to tell the truth and let readers decide for themselves.

— Kimball Atwood, Science Based Medicine, Bravewell Bimbo Eruptions

I had been too inarticulate to formulate what is essentially my approach to this blog: to tell the truth. That would appear to be simple enough. Of course it gets down to what constitutes the truth, and whether you can handle the truth.

What is truth, small ’t’? Truth with a big ’T’ is provided by belief systems that originate in a personal epiphany and you suddenly understand the meaning of life, the universe and everything. Or conjure up reiki or chiropractic. I suspect I was either born without the part of the brain that allows me to appreciate the mystical/spiritual aspects of human existence, or perhaps it was my upbringing. Probably a bit of both, although having raised two kids in the eternal nurture/nature debate has swayed me heavily towards the nature side of the fence. I bet I was born that way. But I am totally tone deaf to issues of spirituality and the surrounding issues of big ’T’ Truths, so I am going to stick to the little ’t’ truths.

Little ’t’ truths’, or as I like to call them, facts, consists of the approximate understanding of the reality provided by the scientific method. Note the word approximate. I have always liked Richard Dawkins metaphor of science as climbing a series of peaks (at least that is how I remember it, having read the book years ago). Get to the top of one peak, and it provides a vista of understanding, but there is always another peak to climb to offer an even more comprehensive view of the topic. Every year our understanding of reality is refined and extended. Understanding something as ostensibly simple as influenza vaccination gets more sophisticated and subtle every year. It is not as simple as give an antigen, develop an antibody and become immune to that strain of flu. It is the continuing increased understanding of the multiple facets of infectious diseases is in part what makes ID the most endlessly fascinating specialty in medicine.

There are still lots of unexplained phenomena in the universe, but mostly at the extremes of scale: the quantum level and the universe. At the approximation of the human scale, the scaffolding upon which we hang our understanding is quite well worked out. The basic sciences (physics, chemistry, biochemistry, anatomy, physiology, pharmacology, evolution, etc.) that inform our understanding of medicine do not leave any space for ‘new’ concepts. The existing concepts that underlie medicine do not support much of what passes for the underlying mechanisms that are the alleged basis of supplements, complementary and alternative medicine (SCAM’s). If is more to human existence, wondrous strange, I have yet to see it demonstrated.

Horatio:
O day and night, but this is wondrous strange!

Hamlet:
And therefore as a stranger give it welcome.
There are more things in heaven and earth, Horatio,
Than are dreamt of in your philosophy.

If there are phenomena at the human scale that exist outside our understanding of the basic sciences, it has never been demonstrated over and above the ability for humans to convince themselves that magic exists. My philosophy seems pretty comprehensive

At some level I am not a ‘true’ skeptic, since given the current understanding for the reality, the following not only do not exist, but cannot exist. Their prior probability is zero. A true skeptic would give credence to the possibility, however small, that a counterexample could be produced to confirm the reality of some bit of pseudoscience. The following incomplete list do not and cannot be true, small ‘t’, and are fictions:

  • Telepathy
  • Astrology
  • Psychics
  • Talking to the dead (or at least the dead talking back)
  • Homeopathy
  • Chiropractic subluxations and all interventions that derive from that idea
  • Meridians and chi, and all interventions that derive from the idea
  • Energy medicine
  • Reiki
  • Therapeutic touch
  • Iridology
  • Reflexology
  • Craniosacral therapy
  • Large swaths of naturopathic training,

It reinforces the idea that science based medicine is reality based medicine. SBM is based on facts and small ’t’ truths. While SCAM’s use the tools of science, much of the underling conceptual framework is imaginary. Dr. Hall’s idea of Tooth Fairy Science conceptualizes the idea perfectly.

There is a lot of uncertainty in medicine, both diagnostically and therapeutically. What does the patient have and how best to treat it can be very complex and the often the most reliable diagnostic intervention, the autopsy, is refused by the patient. The uncertainty in medicine is still within the framework of the sciences and the difficulty in the sorting through the great variability of disease presentation and treatments requires no understanding of CSF tides, energy blockages or Laws of Similars.

Chronic Fatigue Syndrome, CFS, is perhaps a good example where medicine fails. There are still no diagnostic or therapeutic interventions that shed light on the disease or improve the quality of life for the patients. I remain reasonably convinced that a subset of CFS patients have an infectious trigger, and that someday we will have an understanding of the pathophysiology of these patients. I do not think it is ‘all in their head’, although as Takotsubo cardiomyopathy demonstrates, there is a mind-body connection, just not the mystical connections promulgated by many SCAM providers. There are no features about CFS to suggest its etiology will not eventually be amenable to understanding. As I have mentioned before, humans operate within very narrow physiologic parameters and have a limited repertoire with which to respond to the environment and CFS appears to be variations on a theme.

In medicine we have an understanding of truth, of reality, an expanding collection of facts and their interrelationship, provided by the basic sciences. At the center of medicine is applying that reality as best as is possible to ill, frightened people. The ill are vulnerable. When you are sick you often do not have the luxury to search for the best product available, like finding a TV on consumer reports. And even if you have the time, the complexity of medicine may preclude a good understanding of what the diagnosis and therapy. Hell, when I had my lipids checked, my primary said they were bad. She started to talk about LDL and HDL and ratio’s and risks and I stopped her. I didn’t care. I have better things to occupy my neurons with than lipids; I have blogs to write. What did I need to do? Lose weight. So I did. Now my lipids are fine. Just do not ask me what my numbers are or what they mean. I don’t care to learn the ins and outs of lipids; I trust my doctor.

There was a time when medicine was less standardized and reality based. At the beginning of the 20th century there were multiple competing forms of medicine and no standardization of medical education. Becoming a doctor could be as easy as hanging up you shingle, declaring that since you cured deafness with a pop of the spine, you were a doctor and a healer. Because of the hodgepodge of disparate medical practices and the lack of an organized medical education, the Carnegie Foundation financed a review of medical education in the United States. Authored by Abraham Flexner,  for some unknown reason it became known as the Flexner Report, and it became the foundation for the standardization of medical education.

The Flexner Report resulted in a reorganization of medical schools and gave rise to the system of medical training in use today. Among the many changes was a clear delineation between those aspects of medicine that were science/reality based and those that were not: chiropractic, homeopathy, and naturopathy.

When Flexner researched his report, “modern” medicine faced vigorous competition from several quarters, including osteopathic medicine, chiropractic medicine, eclectic medicine, naturopathy and homeopathy. Flexner clearly doubted the scientific validity of all forms of medicine other than that based on scientific research, deeming any approach to medicine that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that offered training in various disciplines including eclectic medicine, physiomedicalism, naturopathy, and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support.

The last 100 years has seen the proliferation of reality based biomedical sciences and there has been a similar proliferation of fantasy based SCAM’s that, one would think, would have no reason to be included in modern medicine. The Flexner report had put medicine firmly on the path of reality/science based medicine, which I would argue is the ethically based medicine as well. Diagnosis and therapies based upon what is, well, made up shit, should have no utility in medicine. Ill, vulnerable people should not, one would think, have their lives, their health, and their finances put at risk on the basis of fictions. This is the point in the essay where someone will mention Vioxx. Thank you. Vioxx bad. Got it. Vioxx gone. SCAMs persist. That is the important difference.

Fast forward 100 years to the Bravewell report. Many of the issues of the Bravewell report have already been discussed by Dr’s Gorski, Novella and Atwood; I might as well pile on. What is striking about the report is how many of what I would have thought of as premier medical institutions in the US have repudiated science and reality in favor of fantasy based medicine. These are what I would have thought of as top notch medical centers: UCSF, Scripps, Vanderbilt, Duke, Cleveland Clinic and MD Anderson are on the list.

As always with proponents of SCAM’s there is a spectrum from legitimate therapists and therapies to the completely wackaloon. I am going to limit myself to the 100% fantasy based wackaloon SCAMs offered by institutions who really should have known better. But that’s me. I do not think popularly and profit should trump truth and integrity. Shame, I guess, is not a concept embraced by our ‘top’ medical centers.  I am using quotes; I worry that soon I will be typing in caps and using multiple exclamation marks, the sure sign on the web that the writer is unhinged.

70% of these institutions employ an acupuncturist, 62% a TCM practitioner, 38% a chiropractor, 28% a naturopath, 17% an ayurvedic practitioner, 17 % a homeopathy practitioner. Almost one in 5 think it is legitimate medical practice to offer water to treat their patients. The mind boggles. If your medical institution has so little grasp of reality that they hire homeopaths and their fellow travelers, the naturopath, time to seek care elsewhere. 38% have hired a holistic nurse, what ever that is.  Probably who is doing the reiki and therapeutic touch. Other fantasy based therapists employed included energy psychologist, Feldenkrais practitioner, Qi Gong practitioner, and a reflexologist.

Of the 29 centers 15 used healing touch or reiki for cancer or chronic pain. Legitimate medical centers waving hands over patients to treat cancer. Really, there is no shame. None. Evidently they are proud of the fact; I am sure the Board of Directors is pleased. For asthma, 9 used healing touch, 4 used chiropractic, 3 used homeopathy. For cancer, 15 used reiki, 15 used healing touch, 4 used homeopathy. For diabetes, 7 used reiki, 5 healing touch, 2 homeopathy.  These are real diseases with well known pathophysiologies and complications for which they offer magic.

Interestingly, for diabetes,  only 24 of 29 used “food/nutrition” and 18 of 29 used “exercise/fitness” in their therapies And here I thought diet and exercise were the mainstay of diabetes treatment. Same with heart disease with 24 of 29 used “food/nutrition” and 20 of 29 used “exercise/fitness” and for obesity with 25 of 29 used “food/nutrition” and 24 of 29 used “exercise/fitness.”  I wonder, rather than diet and exercise, how they treated diabetes, obesity and heart disease; the lists suggests probiotics, therapeutic touch, reiki or homeopathy.

And post operative care? 3 of 29 used endurance training or Pilates.  Doesn’t seem, off hand, to be the best time for endurance training. They are probably not getting the patient ready for an iron man after their hip replacement. Or I would hope. Given the approach to diabetes, obesity and heart disease, I am not so sure.

It gets worse: 38% have on site retail sales of homeopathy, 21% from their website, and 7% from pharmacy or gift shop. They are selling water and are happy to proclaim it to the world. Similarly 48% gave on site retail of TCM or Ayurvedic, 21% from their website, and 3% from pharmacy or gift shop, and 38% have on site retail of AROMATHERAPY (!!!!!!!!!) , 17% from their website, and 7% from pharmacy or gift shop.

It is a serious question: Why not have a psychic on staff to predict the patients course? Or have John Edwards visit after a patient dies so that the family can talk to their dead? Does anyone see any difference between those interventions and the ones already offered? I can’t. Major medical institutions are offering fiction to their patients.

It would be nice, or at least easier, to practice in one of those institutions. Where I work I have to justify adding new drugs to the formulary. We review the costs and benefits of new interventions and decide, based on the available data, if an antibiotic should be added to the formulary. We have to follow standards and review the literature. If I were to practice at Duke or Scripts, I could do whatever I damn well pleased. They evidently have no  standards of care since and any institution that sells homeopathy should have no institutional credibility to control their pharmacy.

Flexner was a fool for thinking

Such exploitation of medical education … is strangely inconsistent with the social aspects of medical practice. The overwhelming importance of preventive medicine, sanitation, and public health indicates that in modern life the medical profession is an organ differentiated by society for its highest purposes, not a business to be exploited.

A scientific basis of medical care and medicine have a higher purpose. I love humor. As the Bravewell report says “cash remains the most frequent form of payment.” When the choice is between reality and an exchange of fantasy for money, as Las Vegas demonstrates, fantasy wins.

The humor continues in the Bravewell report. They report that clinical success is based in part on “Using an evidence-informed approach to care.” I presume for those institutions that offer the fantasy based therapies, the evidence is from billing and collections, not Pubmed.

While most of the institutions measure patient satisfaction, the results of those measurements are not mentioned. I would bet that patient satisfaction is high. Unfortunately,

higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.

That may be why they do report outcomes. I would postulate that high satisfaction with your alternative care would be associated with increased mortality.

My bias is that medicine should be based on the best approximation of reality that the scientific method can provide. Science based medicine is reality based medicine. The forms of therapy offered by what used to be considered top notch medical institutions are neither based on science nor reality, but I understand that popularity and profit are more important than honesty and integrity. That’s the wave of the future. I was always under the impression that you can judge of person by the company they keep.

One of the most striking, though perhaps predictable, conclusions of this study is that integrative medicine is, in fact, integrative. It integrates conventional care with non- conventional or non-Western therapies; ancient healing wisdom with modern science; and the whole person—mind, body, and spirit in the context of community.

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.

I had long thought that the laws of thermodynamics prohibited perpetual motion machines. No longer. If we can some how harness the kinetic energy of Flexners corpse, we would no longer have to import oil. At the rate it must be spinning, it is probably going to rotate forever.

Posted in: Health Fraud, Medical Academia, Medical Ethics

Leave a Comment (132) ↓

132 thoughts on “Perpetual Motion: More on the Bravewell Report

  1. mattyp says:

    An excellent post Mark. I would point out though, this was always my understanding of “the truth”:

    http://www.youtube.com/watch?v=htVkGx4_GqA

  2. sarah007 says:

    Mark said “I have always liked Richard Dawkins metaphor of science as climbing a series of peaks (at least that is how I remember it, having read the book years ago). Get to the top of one peak, and it provides a vista of understanding, but there is always another peak to climb to offer an even more comprehensive view of the topic. Every year our understanding of reality is refined and extended.”

    This is very revealing, this idea of peaks and a bit more understanding is hardly scientific, if we taught people to fly planes like this there would be far more crashes. This cobble together thinking that Dawkins spouts is usually what happens when people keep changing their stories to fit the evidence and usually implies that one does not have a grasp of the subject.

    Mark said “The basic sciences (physics, chemistry, biochemistry, anatomy, physiology, pharmacology, evolution, etc.) that inform our understanding of medicine do not leave any space for ‘new’ concepts.”

    This is a religious point of view, we have the truth so no one else can challenge it, again little evidence of science here either, what about Dawkin’s idea of mountains here, what would you do if evidence showed that vaccines actually shift the disease burden towards say allergy, religiously defend the basic sciences?

    Mark said “The existing concepts that underlie medicine do not support much of what passes for the underlying mechanisms that are the alleged basis of supplements, complementary and alternative medicine (SCAM’s).”

    This again is not scientific reasoning, Newton doesn’t fit with quantum physics so which is wrong, if you were a scientists you would at least pose the thought that the underlying concepts of medicine might be wrong. To state that it catagorically is not is a religious point of view.

    Mark said “If there are phenomena at the human scale that exist outside our understanding of the basic sciences, it has never been demonstrated over and above the ability for humans to convince themselves that magic exists. My philosophy seems pretty comprehensive.”

    Unbelievable really, what about love and hope Mark. Your philosophy is one dimensional and that doesn’t make it more valid, just because you can’t weigh it or smell it or feel it it doesn’t make an event unreal.

    Mark said”SBM is based on facts and small ’t’ truths. There is a lot of uncertainty in medicine, both diagnostically and therapeutically. What does the patient have and how best to treat it can be very complex and the often the most reliable diagnostic intervention, the autopsy, is refused by the patient. ”

    Mark this seems like you are covering all angles, where is this SBM certainty? These are the critiques you make of things that don’t fit your idea of ‘reality’. Seriously if you are trying to convince a third party who is unsure of where they are going this post is fail.

  3. Michelle Beissel says:

    Really enjoyable read and very informative, especially those percentages of “top” medical institutions embracing magic. Unfortunately (per Sarah), the die-hard embracers of magic will gloss over your very compelling argument. It is impossible to teach someone something they don’t want to learn. Science-based practitioners don’t love and hope? I say their hope is way more authentic because they are discriminating enough to use science upon which to base their treatment. I have endured this ‘wonderful’ focus of supposed love and hope by cranks, my wallet got very thin, and I stayed sick. I learned the hard way, after decades of using alternative medicine, what a load of crap it is.

  4. windriven says:

    “What is striking about the report is how many of what I would have thought of as premier medical institutions in the US have repudiated science and reality in favor of fantasy based medicine.”

    And deeply depressing. It isn’t just the pandering to scratch a few more bucks into the till, it is the imprimatur bestowed on gobbledygook. Hah-vahd offers it so it must be fabulous.

    The world is full of rubes and the predators who prey on them. For the rubes there is no spear of truth, logic and reason that will penetrate their kevlar-sheathed stupidity. Too bad they can breed. Perhaps the best strategy is to abandon them to their fate; let society bifurcate along the line of reason like some Margaret Atwood dystopia. Let them go. As in politics, this is a battle for the minds of the uncommitted.

    So what to do about the predators who find themselves in positions of authority? They are like intellectual black holes pulling those who stray too close over the event horizon and into rubedom. What to do when Harvard embraces a charlatan like Ted Kaptchuk and calls it academic freedom? You have to wonder: How much of a gift to Harvard would it take to expand the definition of academic freedom to include a Department of Creationism or Applied Alchemy?

  5. rbnigh says:

    I agree with you in general and share your philosophy. I think being a scientist means a committment to gathering small ‘t’ truths, facts, and insisting that our explanations be be consistent with all those facts. If we don’t have an explanation we are committed to seeking more truths until things become clear.

    Yet I really don’t see how you can say:

    “At the approximation of the human scale, the scaffolding upon which we hang our understanding is quite well worked out. The basic sciences (physics, chemistry, biochemistry, anatomy, physiology, pharmacology, evolution, etc.) that inform our understanding of medicine do not leave any space for ‘new’ concepts”

    Pardon me, but this is absurd. There is no set of facts that you can cite to support this statement, it is pure faith in a capital T Truth, Science. I am reminded that often in this blog that if some fact, some apparent truth contradicts the SBM paradigm, say give support to the efficacy of acupuncture, it is dismissed with the argument that a conclusión must ‘make sense’ according to current scientific understanding. This is completely circular reasoning, a typical approach by people defending a Truth. (eg, everything in the bible must be true or god wouldn’t have put it there!)

    Our scientific understanding of the human scale is not “well worked out”. We don’t even understand the placebo effect, though science-based medicine has been forced to include it in its experimental design. In medical anthropology there is a set of facts about human behavior that we attempt to understand. How do people perceive disease and undertake to cure themselves? Do the things they do actually work? Do the things they do make their sickness worse (often that seems to be the case)? If they don’t work, why do they keep doing them generation after generation? Is everybody except scientists hopelessly irrational? How does the mind-body connection we run into so often actually work? What is ‘mind’ according to current scientific understanding? What role does culture play in healing?

    I don’t have the answers to these questions but I think if we are to answer them as scientists a little less hubris is in order. I suspect you are right that the explanations will not come from most of the list of fictions you provide. But the answers will be full of surprises and will make your currently “well worked out” understanding look like a bunch of phlogiston. To recognize that our current “reality based” explanations are inadequate to deal with many ‘truths’ we encounter is not fantasy but real science-based medicine. If we don’t know the answers, an evidence based approach requires us to be open to other possiblities, even if they seem to contradict our Truth. I don’t think it is rational to criticice medical institutions for being open to evaluating alternative practices.

  6. rork says:

    Maybe it is time to take “integrative” away from the quacks, by using that term for modern medicine that uses multiple methods. Let them keep “alternative”. It might be what Weil wants, just taken to an extreme so that quacks can’t qualify.

    I think there is space for new concepts (I supply my own definition of concept perhaps). Endogenous small RNAs have changed my (all too basic) research world. Sorry if we don’t have developed weapons in your hands yet. The details of the lives of histones has been pretty interesting too, whereas we were just looking at the methylation of cytosines earlier. I’m liking the new aptamer work too, where I can guarantee new weaponry. Yes, I admit this is just chemistry, but the point is it is exciting times, still. There’s also been many lessons in the last 20 years about how we have fooled ourselves by not thinking straight (for example: benefits of screening).

  7. Pman says:

    I am much more interested in the aspects of CAM that get strong-armed off the formulary because they are NOT monetizable.

    Than the aspects of CAM that get strong-armed on the formulary because they ARE monetizable.

    With the recent NEJM article, is Tai Chi now part of conventional medicine?

    You expect me to believe it will be a regular offering across the country?

    Likely it will be part of (evidence-based) CAM.

  8. Jojo says:

    Mark, this is a wonderful post. I really enjoyed it. Thank you.

  9. cervantes says:

    The basic sciences (physics, chemistry, biochemistry, anatomy, physiology, pharmacology, evolution, etc.) that inform our understanding of medicine do not leave any space for ‘new’ concepts.

    There’s no sense arguing with Rbnigh, but I think this statement is imprecise and gets you into some trouble. Of course there is plenty of room for new concepts in all of these disciplines, that’s what drives scientists’ work. I believe you mean to say that within these disciplines there are some firmly established concepts on which further understanding depends, and which it would require extraordinary evidence to modify. But there are plenty of new concepts to discover beyond what we already know, and some concepts we believe now which will no doubt be overturned.

    At the same time, there are emergent properties as we move up through levels of complexity, from the most reductionist level of physics, through chemistry, biology, to psychology and sociology which you don’t mention, and which are certainly both essential to medicine. I would venture to say there are still some pretty fundamental concepts remaining to be discovered in psychology and social psychology. And it is precisely within this mysterious realm that the scammers work their mischief.

  10. mdstudent says:

    @ Pman

    The health benefits of exercise and stress reduction techniques (ex tai chi) have long been recognized and promoted by sbm.

    Can you name some specific examples of “aspects of CAM that get strong-armed off the formulary because they are NOT monetizable”?

    @ rbnigh

    I think you’re misunderstanding Mark’s statement. He isn’t claiming that modern medicine has a complete understanding of how the human body works. He’s saying that our basic understanding of the basic processes that are covered in the basic sciences is solidly grounded in hard evidence. Any expectation that they can one day be overthrown by a single over-arching breakthrough (ex the discovery of an invisible bio-energetic field that pervades and governs the behavior of all living things thereby negating the laws of thermodynamics and osmosis) is silly.

  11. Scott says:

    I know I shouldn’t, but when I see this I just have to:

    Newton doesn’t fit with quantum physics so which is wrong

    Neither. Newtonian mechanics is an approximation of quantum mechanics which applies at the macroscopic scale, and simultaneously an approximation of relativity which applies at velocities much less than c. It’s actually a perfect example of Dawkin’s point – science proceeds as a series of progressively more accurate and general approximations of reality.

  12. windriven says:

    @rbnigh-ted

    “I am reminded that often in this blog that if some fact, some apparent truth contradicts the SBM paradigm, say give support to the efficacy of acupuncture, it is dismissed with the argument that a conclusión must ‘make sense’ according to current scientific understanding. ”

    Horse hockey. You are entitled to your own views but not your own facts. SBM does not dismiss evidence with the assertion that it must make sense. SBM takes the position the generally accepted scientific position that extraordinary claims demand extraordinary proof.

    A putative therapeutic procedure like acupuncture that relies on notions like qi and meridians that are unknown to science has a higher burden of proof than does one that builds on established scientific fact. You may believe that magic water cures hep-C but absent some very compelling proof you will stand nearly alone.

    Look, science is a rough and tumble sport. The battle to demonstrate the helicobacter pylori was often the cause of gastric ulcers was long and bloody (if you’ll pardon the pun) because it was a radical departure from the then current medical mainstream. It had to be proven to a very skeptical audience that it was the real deal. But once proved it was universally embraced.

    Compare and contrast with poking needles in your qi, G. The fact that a few studies suggest an infinitesimal response barely distinguishable from background noise does not rise to the level of, to use your words, “apparent truth”.

  13. rbnigh

    “Our scientific understanding of the human scale is not “well worked out”. We don’t even understand the placebo effect, though science-based medicine has been forced to include it in its experimental design ”

    First of all, if you read the entire statement Mark made it seems pretty obvious that Mark wasn’t saying we’ve completely worked out a total and complete understanding of human physiology and health such that there are no mysteries left to answer.

    It seems pretty clear that Mark was likely talking about our scientific understanding of physics and the nature and operation of the universe on the size scale of a human being as opposed to the very small (quantum physics) or the very large (cosmology). Our understanding of the universe on a human scale (or the scale of a corn stalk if you prefer) is very well worked out, and this understanding of the universe is sufficient to use in developing our understanding of medicine.

    I don’t consider placebo effects to be quite as mysterious as you seem to (we have pretty good basic explanations for much of what is called the placebo effect), but regardless, although there are many things we still don’t understand about human health and physiology, we do pretty much have all the basics worked out, such that we can rule out chi/meridians/vital force/energy medicine, water memory, etc. There is still much yet to be learned and discovered, but any new discoveries are likely to build on top of our current understanding of physics, chemistry, biochemistry, anatomy, physiology, pharmacology, evolution, psychology, etc. rather than from a revolutionary & dramatic new paradigm.

    Further explanations of the various placebo effects is likely to come form an understanding of biochemistry, anatomy, physiology, psychology, etc rather than something completely outside current scientific understanding.

  14. David Gorski says:

    I like to put it this way with respect to something like homeopathy, the ultimate quackery. For homeopathy to be true, science would have to be not just wrong but spectacularly wrong about huge swaths of what are considered now to be well-established science. These included physics, chemistry, biochemistry, and several other fields. Is it possible that science is so spectacularly wrong about so many areas generally considered well supported by evidence? Theoretically, yes. However, to overthrow such huge bases of knowledge, which are supported by mountains of evidence from multiple fields that all converges on current understanding would take much more than clinical trials that purport to show an effect that is barely above that of the placebo control and could be due to confounders, bias, poor experimental design, or just the random chance alone that guarantees that even in an ideal world at least 5% of clinical trials would appear positive based on our choice of cutoff for statistical significance. It would take something very startling and undeniable (for instance, curing several patients of metastatic pancreatic cancer outright) or an equivalent mountain of counter evidence showing that homeopathy could work to raise homeopathy to plausibility.

    One could easily say the same thing about energy healing and quite a few other CAM treatments.

    What is the likelihood that so much of science built up over hundreds of years is so wrong that homeopathy can be true? Vanishingly small. Theoretically, it’s not zero, but practically it is.

  15. nybgrus says:

    some apparent truth contradicts the SBM paradigm, say give support to the efficacy of acupuncture, it is dismissed with the argument that a conclusión must ‘make sense’ according to current scientific understanding. This is completely circular reasoning, a typical approach by people defending a Truth. (eg, everything in the bible must be true or god wouldn’t have put it there!)

    Incorrect characterization. The premises upon which your “circular reasoning” are based are actually well established, empirically verified, independently replicated, tenets of science. It is NOT circular as in the god/bible analogy since neither of those have been empirically verified.

    So, when acupuncture trials show mildly positive results, and we say that is noise in the data it is not circular and indeed very much how science is done and MUST be done. It is called the prior – a Bayesian framework. You can’t have every known law of physics and chemistry suddenly become invalid after a homeopathy trial shows symptom relief in colds. No, the correct assumption is that it does not fit the extremely well established understanding of science and therefore homeopathy is wrong. Not the other way around.

    So yes, a conclusion must make sense according to the established scientific understanding.

  16. Scott says:

    I think it’s fair to say that what Mark meant was perfectly reasonable and correct, though the way it was phrased could have been better.

  17. Sometimes it’s a good idea to refresh a page before posting a comment to see if several others have already made the same basic comment. :)

  18. Pman says:

    @mdstudent

    Tai chi is compared to resistance exercises in the study.

    Market forces dictate what’s on the formulary. Ornish as first-line for CVD, stress management techniques as first-line for IBD, and acupuncture for chronic migraine are not routinely endorsed by SBM. These become the responsibility of the CAM centers at their respective institutions.

    Let’s give an example of the modality that SBM hates on the most, a stress-reduction technique that does not outperform placebo in the better-crafted studies.

    http://www.ncbi.nlm.nih.gov/pubmed/22019576

    I believe most SBM’ers would recommend topiramate (despite its side effect profile) over recommending acupuncture for lack of a plausible mechanism outperforming placebo. I know, it’s been discussed ad nauseam.

    It would not be ethical, in my opinion, to expose a patient to a medication with a greater deleterious side effect profile than a modality which is not rooted in current scientific concepts which a higher probable efficacy.

    This is not “do no harm.”

  19. nybgrus says:

    lol… mea culpa.

    I wrote my comment and apparently others posted theirs just before mine. It all came up right when I hit submit. Oh well, at least we all picked up on the same point.

  20. nybgrus,

    Just to be clear, my comment was directed at myself as much as anyone else.

  21. Mark Crislip says:

    advances in understanding of placebo or small RNAs are extensions or refinements of what is understood. I expected someone to point to Helicobacter (and they did) as an example of a new concept, but no new energies etc need be postulated. There is nothing about placebo, RNA or helicobacter that requires overturning the basic sciences.

    mdstudent summed it up better than I.

    Writing is an interesting process. Sometimes what seems to clear to me is opaque to others. But, as always, I learn from (most) of the comments

  22. nybgrus says:

    @karl: fair enough.

    @pman:

    It would not be ethical, in my opinion, to expose a patient to a medication with a greater deleterious side effect profile than a modality which is not rooted in current scientific concepts which a higher probable efficacy.

    And it would not be ethical to prescribe something that is known to be nothing more than an elaborate placebo, especially whilst lying to the patient and claiming some sort of chi, meridians, trigger points, counter-irritation, etc which we know to not be the underlying mechanism of action. It has nothing to do with whether it is “rooted in current scientific concepts” it has to do with how it works (or in this case, doesn’t work). See the above comments from myself, Karl, windriven, and Dr. Gorski said regardin this notion.

    From my perspective, the balance of ethics favors the less effective (or equally effective) intervention which does not rely on lying and placebo to effect its symptom relief. If the intervention genuinely has significant enough side effects (Vioxx anyone?) then it should just be removed from the formulary. Otherwise, removing informed consent and patient autonomy is a significantly more egregious transgression, easily tipping the scales away from e.g. acupuncture.

    Doing poor trial after poor trial to try and trick ourselves into genuinely believing there is something more to acupuncture than an elaborate placebo does everyone, and the profession, a disservice.

  23. mdstudent says:

    @ Pman

    The literature demonstrating the efficacy of topiramate as a prophylaxis for migraines against placebos is pretty impressive. Here are a few examples:

    http://www.ncbi.nlm.nih.gov/pubmed/20974598

    http://www.ncbi.nlm.nih.gov/pubmed/19719543

    http://www.ncbi.nlm.nih.gov/pubmed/17300356

    The literature demonstrating the efficacy of acupuncture in treating anything better than a placebo or other standards of care is all over the place and becomes overwhelmingly negative as the quality of the studies increase.

    One study doesn’t prove anything.

    Science is rough.

  24. mdstudent says:

    @ Mark

    “I had long thought that the laws of thermodynamics prohibited perpetual motion machines. No longer. If we can some how harness the kinetic energy of Flexners corpse, we would no longer have to import oil. At the rate it must be spinning, it is probably going to rotate forever.”

    Hilarious!!

  25. WilliamLawrenceUtridge says:

    Dr. Crislip’s comment about how he’s not a “true” skeptic seemed to make his intent pretty clear to me.

    For my own learning – was the issue with Vioxx that it had unreported adverse effects, or that they were much worse than reported, or that they were dramatically worse than comparable treatments? I had thought there were calls for Vioxx to be returned to market because it was the only effective pain medication that worked for some patients, and ultimately the risks were about comparable to currently approved drugs?

    Links (and corrections) appreciated!

  26. sarah007 says:

    Pman said “I believe most SBM’ers would recommend topiramate (despite its side effect profile) over recommending acupuncture for lack of a plausible mechanism outperforming placebo. I know, it’s been discussed ad nauseam.”

    This may be true but most SBMers are not migraine sufferers. Perhaps that’s the difference, you live in a belief system that only meds can help, with migraine only 50% have some relief, with side effects that are not minimal, whilst on meds but they return once off.

    Nybrus said “And it would not be ethical to prescribe something that is known to be nothing more than an elaborate placebo, especially whilst lying to the patient and claiming some sort of chi, meridians, trigger points, counter-irritation, From my perspective, the ‘balance of ethics’ favors the less effective (or equally effective) intervention which does not rely on lying and placebo to effect its symptom relief.”

    What about SSRI’s now known to be a placebo, still prescribed with a medical science woo story about seritonin, why is that still ok? This meds is lying now we know that it is placebo.

    Nybrus said “So, when acupuncture trials show mildly positive results, and we say that is noise in the data it is not circular and indeed very much how science is done and MUST be done.”

    But if it’s a drug you would accept mildly postive as better than placebo. ‘Noise in the date’ is hardly a scientific term either.

  27. sarah007 says:

    Suicide is a side effect of SSRI’s, where are the bodys stacking up for those who went to an accupuncturist and where are the complaining patients?

  28. sarah007 says:

    MD student said “The literature demonstrating the efficacy of topiramate as a prophylaxis for migraines against placebos is pretty impressive. Here are a few examples:”

    CONCLUSION:

    Topiramate 100 mg/day did not prevent the development of CDH at six months in subjects with HFEM

    There we go looked at first one and those with high frequencey episodic migraine got squat tiddly.

    Side effects of topiramate: Depression (see Topamax and Depression)
    Chest pain
    Difficulty breathing or shortness of breath, which may be signs of a pulmonary embolism
    Hallucinations or paranoia
    Fainting
    Vision problems, especially associated with eye pain
    Rapid breathing, which may be a sign of metabolic acidosis
    Decreased sweating, especially when accompanied by a fever
    Blood clots (deep vein thrombosis)
    Suicidal thinking or behavior
    High blood sugar (hyperglycemia) or diabetes
    Kidney stones
    Low blood pressure (hypotension) or high blood pressure (hypertension)
    Signs of an allergic reaction, including: Unexplained rash Hives
    Itching
    Unexplained swelling
    Wheezing
    Difficulty breathing or swallowing

    So that’s a pretty impressive result there med student, I hope you enjoy informing your patients so they can make an informed decision.

  29. Harriet Hall says:

    @Pman

    I don’t consider the study you cited to be one of the “better crafted” ones. It compared multiple visits for an elaborate procedure with all kinds of nonspecific treatment effects to the simple prescription of a pill. In other words, it did not involve a credible control.

    I wonder why they picked topiramate? There are a lot of other migraine prophylaxis drugs that I think are more commonly used.

  30. sarah007 says:

    William darling said “For my own learning – was the issue with Vioxx that it had unreported adverse effects, or that they were much worse than reported, or that they were dramatically worse than comparable treatments? I had thought there were calls for Vioxx to be returned to market because it was the only effective pain medication that worked for some patients, and ultimately the risks were about comparable to currently approved drugs?”

    What a gloss over that is. Medical truth is that 160,000 people worldwide died from explosive heart ruptures that were reported by coroners as ‘looking like a gunshot wounds’. It was only withdrawn when the medical payouts overtook profits, how’s that for medical science responding to data?

    I suppose if you call completely dead an effective pain relief I think you are right return it to the market now and make sure you have shares too. Well done William for flagging this one up.

  31. weing says:

    “If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.”
    Great line. Maybe we should send integrated apple pies to the heads of those schools and institutions? If I were a student at one of those schools, I’d want my money back if the dean didn’t eat the integrated pie.

  32. sarah007 says:

    “I had long thought that the laws of vaccination prohibited perpetual disease pandemics. No longer. If we can some how harness the kinetic energy of Fear and corpses, we would no longer have to import vitamins. At the rate it must be spinning, it is probably going to generate income forever.”

    Pandemic!

  33. weing says:

    “I wonder why they picked topiramate? There are a lot of other migraine prophylaxis drugs that I think are more commonly used.”

    Botox treatments would have been a much more worthy choice.

  34. mdstudent says:

    @ Dr. Hall

    “It compared multiple visits for an elaborate procedure with all kinds of nonspecific treatment effects to the simple prescription of a pill. In other words, it did not involve a credible control.”

    Good point.

  35. EricG says:

    We do have (near)perfect understandings of some things. Otherwise, we wouldn’t be able to even *make* computers, vaccines, cars, IVF, skin graphs, vegetables and so on, to begin with. Whether or not vaccines work as they are supposed to across x y and z population, vegetables contain x y and z nutrients under various farming conditions or computers rob children of a “dynamic natural nurture based development” (or whatever wierd argument may arise against using a computer) is where the knowledge breaks down in clarity and definitiveness – and to no discredit of those attempting to understand those effects or those making their best faith effort to act upon them. I’ve completed exactly 1 IRB proposal and the subsequent study; I have no desire to do that ever again. Kudos to those who pursue understanding for its own sake as their life’s work.

    A possible, more simplistic in any event, restating of what Drs. Gorski and Crislip (and others) have stated about truths and understanding:

    We have accumulated a very large pile of ‘t’s: for homeopathy and other treatments of such dubious nature to be true, we would have to have had mistaken the t’s for lower case, backwards, upside-down ‘f’s…and then go on to explain how those mistaken ‘t’s could have been so useful in making computers.

    I think it is very tempting for people to get sucked into the “anything is possible” frame of mind, but it’s simply not true. There are a fantastic amount of possibilities within this universe. Many we have yet to know, many we may never know. However, there are definitive impossibilities that are rather easy to demonstrate with language:

    A cheeseburger made of earthquakes
    Heart shaped squares
    Pens that write with ink made from my love for puppies
    A four-sided triangle
    Agreeable message board trolls

    For some of us, we cannot conceive of unassisted human flight and chakra healing being impossible, for the rest it merely becomes an addition to the list. We live in a world with constraints, like it or not.

  36. Quill says:

    Thank you very much for what I think is an excellent post, a sound statement of personal philosophy. I was especially happy to see uncertainty addressed for what it is: a fact of life instead of an invitation to wish for certainty based on anything at all instead of knowledge.

    Also thank you for including one of Hamlet’s famous quotations. Isn’t it curious that so many don’t take it as a statement of wonder at the vastness of things (followed by a deliberate decision to “put on an antic disposition”) but rather as a self-satisfying “aha!” where they think this then allows for the inclusion of any mummery or nonsense? Vastness and possibility don’t mean that what’s known as basic science will suddenly be rendered invalid but rather, like those peaks, we can continue the journey based on what we know so far.

    I continue to be well-served by a college mathematics professor who once told me that most of humanities problems stem from an inability to deal with uncertainty coupled with a failure to adequately contemplate infinity.

    And now I think I’ll stroll over to the cafeteria at UCSF and see if I can find an earthquake cheeseburger. Surely they sell them next to the aromatherapy supplies?

  37. lizditz says:

    @windriven: Instead of “rubes”, I’ve learned a new expression from my twitter-friend @kerima_cevik: There is a word in Turkish that translates roughly as “ignorant to an uneducable degree” = zır cahil.

    I apply this to proponents of homeopathy, reiki, chiropractic for anything other than adult low-back pain, the rest of Dr. Crislip’s list….

  38. windriven says:

    @lizditz

  39. windriven says:

    @lizditz

    zir cahil … I love it!

  40. weing says:

    @lizditz,

    Are you sure it’s not two words?

    “Quite difficult matters can be explained even to a slow-witted man, if only he has not already adopted a wrong opinion about them; but the simplest things cannot be made clear even to a very intelligent man if he is firmly persuaded that he already knows, and knows indubitably, the truth of the matter under consideration.” Leo Tolstoy

  41. Pman says:

    @ mdstudent

    Please look up fecal transplantation for refractory c. diff and tell me that it will make it on to the formulary despite clinical superiority (the nasty-ness factor superseded by the a potential outcome of recurrent refractory c. diff = death). My money is on it being ushered in under the auspices of “integrative medicine.”

    @ Mark Crislip

    I remember your old post on probiotics, once banished to CAM-land, but would be curious to see your updated thoughts in light of recent developments (with *emphasis* on developing world research on a recombinant probiotic for treatment and prevention of cholera). Again, most of this research is done outside the US, so I hope SBM is okay with this.

    It will take another decade to bring probiotics out from CAM-land, but when the most effective strains are isolated most SBM’ers will forget that they were ever against it before they were for it, and pretend that they weren’t responsible for preventable premature deaths from necrotizing enterocolitis, etc.

    The big philosophical divide here between SBM and CAM is that SBM has (IMHO, misplaced) faith in the efficiency of the market-based forces in medicine. The ‘huckster’ component of CAM becomes the market, but don’t try and blanket all of CAM with this designation.

  42. Harriet Hall says:

    Pman said “Please look up fecal transplantation for refractory c. diff and tell me that it will make it on to the formulary despite clinical superiority.”

    It isn’t even a candidate for the formulary because it requires fresh collection of live organisms and is usually harvested from a family member, but that doesn’t mean it won’t be accepted. It is already being used in conventional medicine. It is firmly grounded in science, and can’t be classified as alternative.

  43. weing says:

    @Pman,

    “It will take another decade to bring probiotics out from CAM-land, but when the most effective strains are isolated most SBM’ers will forget that they were ever against it before they were for it, and pretend that they weren’t responsible for preventable premature deaths from necrotizing enterocolitis, etc.”

    Are you sure that it will take another decade to bring them out of CAM-land? I wish I had half as much certainty about anything as you do about this. How could we be for or against something that we don’t have evidence for? It’s like saying, “Gee, I am for/against that new Glaxo drug being studied for C. diff colitis.” Doesn’t make sense to me. I mean, I can hope it works, then we will have a new weapon in our arsenal. How can you be so sure it will work before the studies are done? It boggles the mind.

    What do you mean by “faith in efficiency of market-based forces in medicine.” anyway? CAM doesn’t believe in advertising?

  44. lizditz says:

    #weing d’oh should have written “phrase” or “expression”.

    I also found this recently: Dietary and nutritional treatments for attention-deficit/hyperactivity disorder: current research support and recommendations for practitioners

    In guiding patients, clinicians can apply the SECS versus RUDE rule: treatments that are Safe, Easy, Cheap, and Sensible (SECS) require less evidence than those that are Risky, Unrealistic, Difficult, or Expensive (RUDE).

    While the authors developed the metric for evaluating ADHD treatments it can be widely applied.

    #Pman: I have been following the literature on fecal transplantation since it showed up on an autism parents’ discussion list as an autism treatment (I’m not joking: Discussion of DIY fecal transplant as autism treatment and Account of home fecal transplant as autism treatment..)

    Turning back to reality, the literature on fecal transplant for c. difficile only goes back to June of 2009 — not even three years yet. And I didn’t realize until I read Standardized Frozen Preparation for Transplantation of Fecal Microbiota for Recurrent Clostridium difficile Infection what some of the other barriers were.

    Still in reality-land: also see The shortcomings of clinical trials assessing the efficacy of probiotics in irritable bowel syndrome

  45. Mark Crislip says:

    GI is doing fecal transplants at my institution for refractory C. diff, it is effective and my probable topic for next post along with probiotics and related issues. Assuming I do not gag.

  46. sarah007 says:

    Weing wong again said ““Gee, I am for/against that new Glaxo drug being studied for C. diff colitis.” Doesn’t make sense to me. I mean, I can hope it works, then we will have a new weapon in our arsenal. How can you be so sure it will work before the studies are done? It boggles the mind.”

    Remember the recent ‘outbreaks’ of e coli 157 that is killing people, press blaimed it on organic cucumbers etc. Well did you know that cows fed on high starch corn, like they do in the USA on factory farms, their gut fills up with e coli 157 within days. Guess what the way to get rid of it is? Feed them grass, the whole gut repopulates with normal flora naturally without any meds.

    What is the solution of meat produces in USA? To spray all meat from e coli cattle with ammonia to kill the bugs. How’s that for ‘medical science in action’ I hope it works, good job I don’t eat it.

    Eric you forgot something on your list:

    A cheeseburger made of earthquakes
    Heart shaped squares
    Pens that write with ink made from my love for puppies
    A four-sided triangle
    Agreeable message board trolls
    Medical science

    Quill said “And now I think I’ll stroll over to the cafeteria at UCSF and see if I can find an earthquake cheeseburger.” Get your litmus out and check for alkalinity.

  47. mdstudent says:

    @ Pman

    I don’t know anything about fecal transplantations and have only recently begun covering basic bacteriology.

    I’ll have to do my homework and get back to you.

  48. lizditz says:

    My personal response to the current troll: ignore. Even when she’s race-baiting.

  49. mattyp says:

    What is the source of this information regarding the E coli 157 outbreaks?

    It seems a little far fetched a theory to me that everyone in the meat industry could be “in” on this, without it being worldwide news.

  50. lilady says:

    (I’ll hate myself in the morning for wading into the Troll’s cow sh**)

    “Remember the recent ‘outbreaks’ of e coli 157 that is killing people, press blaimed it on organic cucumbers etc. Well did you know that cows fed on high starch corn, like they do in the USA on factory farms, their gut fills up with e coli 157 within days. Guess what the way to get rid of it is? Feed them grass, the whole gut repopulates with normal flora naturally without any meds.”

    http://www.ncbi.nlm.nih.gov/pubmed/12935748

    Really Troll, you need to stop visiting foodie websites and you need to stop substituting your Google U. degree for an education in biology, chemistry, biochemistry, immunology and epidemiology.

    @mdstudent: I remember reading about fecal implants and a comment I posted somewhere (here?), about this medical intervention.

    @ Dr. Crislip: Truly a great article and thanks.

  51. nybgrus says:

    @pman:

    It will take another decade to bring probiotics out from CAM-land, but when the most effective strains are isolated most SBM’ers will forget that they were ever against it before they were for it, and pretend that they weren’t responsible for preventable premature deaths from necrotizing enterocolitis, etc.

    Actually the stance on probiotics amongst the SBMers here is exactly that – they have prior plausibility and could prove fruitful, but as of yet have not panned out. Isolating the proper strains, plus metrics for determining who gets what strains, as well as an effective delivery method will be the way to incorporate it into actual medicine. Until then, what is currently available is just a good idea with no substance.

  52. sarah007 says:

    Article Lilady posted from pubmed on ecoli 157 and feeding cattle”doubly cannulated into the rumen and duodenum were inoculated with E. coli O157:H7.”

    Classical medical science false construct. Injecting a load of shit into the bowel is not the same as the flora gradually changing due to changing the diet to an unatural one.

    “from hay-fed or grain-fed cattle” also I didn’t mention grain, I said corn fed and grass.

    You’re research maybe completely right that feeding cattle on an unatural diet of hay or grain makes no difference to how the body deals with a medical twit injecting crap into their guts. But this is not what I said fantasy cake.

    If this is the best you can do I can only pray that you are not my physician.

  53. sarah007 says:

    Nybrus said “Actually the stance on probiotics amongst the SBMers here is exactly that – they have prior plausibility and could prove fruitful, but as of yet have not panned out. Isolating the proper strains, plus metrics for determining who gets what strains, as well as an effective delivery method will be the way to incorporate it into actual medicine. Until then, what is currently available is just a good idea with no substance.”

    Maybe, but who the hell needs that kind of ‘validation crap’ when it works, by the time you have done the studies it will be 10 years and no one will be interested and you will probably find that you can’t isolate the active ingredient and patent it either!

    How many times must one read this fairy story approval nonsense? What’s your idea of an ‘effective delivery method?, innoculation, how about eating or is that too natural?

  54. sarah007 says:

    Since when was hay or grain a natural unprocessed diet, this is a rediculous comparative to your gross misunderstanding Lilolady and I can’t believe that you even thought it up!

  55. sarah007 says:

    Article Lilady posted from pubmed on ecoli 157 and feeding cattle”doubly cannulated into the rumen and duodenum were inoculated with E. coli O157:H7.”

    Classical medical science false construct. Injecting a load of shit into the bowel is not the same as the flora gradually changing due to changing the diet to an unatural one.

    “from hay-fed or grain-fed cattle” also I didn’t mention grain, I said corn fed and grass.

    You’re research maybe completely right that feeding cattle on an unatural diet of hay or grain makes no difference to how the body deals with a medical twit injecting crap into their guts. But this is not what I said fantasy cake.

    If this is the best you can do I can only pray that you are not my physician.

  56. lilady says:

    @mdstudent: I remember reading about fecal implants and a comment I posted somewhere (here?), about this medical intervention.

    Here, I located my comment (#33) on this Respectful Insolence Blog (I was commenting on another post that was advocating high colonics AND fecal transplants as treatment for “whatever ails ya”).

    http://scienceblogs.com/insolence/2011/08/regularity_uber_alles_revisited.php

  57. sarah007 says:

    Matt said:
    “It seems a little far fetched a theory to me that everyone in the meat industry could be “in” on this, without it being worldwide news.”

    I found out about it, do you seriously just believe anything published in a medical peer reviewed journal without looking around. Don’t tell me you eat bigmacs because you believe everything ronny says?

  58. mattyp says:

    @sarah007:

    No, I don’t eat Big Macs. I prefer a Might Angus burger if I’m on the run. I don’t eat it because it’s good for me. I eat it for the delicious BBQ sauce. yummmm.

  59. Purenoiz says:

    Damn it somebody fed the teenage troll again. See how she easily confuses feedlots for medical science. It all fits into the “I can’t understand it so I don’t like it” category. This is how the mind of said troll works, if it requires work to understand, it is bad.

    It’s not like cattle ranchers and feedlots have a financial incentive to grow cows fast and cheap. Something I find repugnant, and yet I understand the motivation and the effects of said processes. Only an a person incapable of basic math skills could fail to see that there is insufficient arable land for grazing animals to roam free & feed a nation of meat eaters. You think people rioting over a rice shortage in 3 world countries is bad, wait till bubba is paying $25/lb of ground beef. Then we shall see food riots of “gigantic proportions”

    Troll kalla mik
    trungl sjǫtrungnis,
    auðsug jǫtuns,
    élsólar bǫl,
    vilsinn vǫlu,
    vǫrð nafjarðar,
    hvélsveg himins -
    hvat’s troll nema þat?

    A nice description of the troll and her onion stories.

  60. mdstudent says:

    @ lilady

    Thanks for the link, I’ll give it a read.

  61. sarah007 says:

    Lilady posted from USDA “Animals cannot be fed grain or grain byproducts and must have continuous access to pasture during the growing season.”

    So your origional paper citing the use of grain fed and hay fed relates well to this post, do you just put up anything with an official label and rub on it? Also US factory farm estates with thousands of cattle all fed remotely via hoppers eat corn based foods, there is no grass on these farms, again nothing to do with your EB attempt to pull it all down!

    Sorry but the Slate article that magically u turns the idea of grass fed no difference uses the same earlier flawed study you posted where cows were fed grain or hay, neither are grass and had e coli 157 canulated, directly into the gut. I am enjoying reading the crap you believe in as it helps me understand why so many doctors are stupid.

    “Mature Angus steers, doubly cannulated into the rumen and duodenum were inoculated with E. coli O157:H7 and fed on grain or hay.” How does this compare with raw feeding exactly?

    A proper trial would put cattle in a field eating grass, the second field has cows on no grass but corn. Both groups start with no e coli 157 and then we wait to see who gets there first. We then test the reversal condition and see how long it takes to go. I saw a food industry scientist explain this in a film, so they know about it. You can find the film quiet easily it was shot on a factory farm, it’s a known problem.

    Looks like Slatey boy is reading off the same sheet you are, quote any crap with CDC, NIH or pubmed and it’s sold. I am really getting this here that being a doctor just needs blind faith in bullshit to proceed and above all total allegence to the cloth.

    Anything that demonstrates questioning, however rational is vomited over and the praying starts, Halleluya

  62. sarah007 says:

    Hey purile and med student you need to read the studies that Lilady posted in her defence, they do not support her position at all.

    Saying you are going to test grass fed against corn fed and then test hay fed against grain does not equate. I don’t actually give a toss, if people like you are eating this crap it is a kind of natural selection.

    Only a true believer would put their head in a gas oven with a lit match, because, wait for it, some blogger called slatey has found an article that shows it’s ok to eat crap! It is really funny that you are so desperate to prove me wrong you can’t even see that the butt has dropped out of your argument.

    Keep posting, if this is the cream of the orthodox crop showing EBM at its best then you are so helping me make up my mind.

  63. sarah007 says:

    Purile said “See how she easily confuses feedlots for medical science. It all fits into the “I can’t understand it so I don’t like it” category.”

    Uhh, P baby the study was supposed to check out that grass effectively protects the gut from EC 157 and that feedlot cattle bred the infection. So what does medical science do, it tests something else against something else and disproves something else. Where was the grass comparison with the feedlot in the study?

    If medical science needs to use this kind of bull to support its position then it’s worse than I could imagine. I can’t actually believe that you guys are training or trained in anything, well maybe you are potty trained?

  64. BillyJoe says:

    “ignorant to an uneducable degree” … I apply this to proponents of homeopathy, reiki, chiropractic for anything other than adult low-back pain, the rest of Dr. Crislip’s list….”

    You forgot our little pet, sarah. :D

  65. BillyJoe says:

    …oops, no you didn’t :D

  66. BillyJoe says:

    …shit, how am I going to get to sleep now after that belly laugh!

  67. magonzalezdmd says:

    Excellent post. It is saddening, as a periodontist, to see “holistic” being applied to dentistry as well. Patients rights be damned, is what goes through their minds.

  68. JimTx says:

    …the life expediency for the last century increased by almost half…almost…the ONLY difference from the last centuries to the present has been clean drinking water, processed food and medicine…and what do we seem to fear?…our water supply, processed food and medicine…and Muslims….we do heat and cool our caves a bit better and food keeps better in the fridge than in the cellar or ice house…but pretty much everything else is the same…beat on a drum…pound on a Blackberry…and there’s a billion Muslims and you could fit all the suicide bombers that ever went bang onto a HS football field,when they were all in one piece…

  69. norrisL says:

    higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.

    or, in other words, “less is ……less”

    when will governments around the world get off their arses and do something about this garbage?!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

  70. pmoran says:

    Norrisl, those findings referred to a seprate study which, so far as I can see, did not distinguish between conventional care and CAM.

    It is possible that very high consumers of health care will have higher mortality, through greater exposure to its known risks. Health economists have long known that those countries with the highest expenditure on health care do not necessarily have better measurable outcomes.

  71. BobbyG says:

    “Health economists have long known that those countries with the highest expenditure on health care do not necessarily have better measurable outcomes.”
    __

    Cites?

  72. pmoran says:

    Cites?

    Bobbyg, any textbook on health economics will go into this. A brief search yields one analysis — http://www.piie.com/blogs/?p=516

    Such findings presumably provide the basis for the tacit, de facto rationing of health care services (through control of doctor numbers, waiting lists for appointments and for surgery, expenditure caps etc) that apply within most national health care systems (and HMOs?).

  73. sarah007 says:

    Billy joe you need to read the thread “Uhh, P baby the study you presented was supposed to check out that grass effectively protects the gut from EC 157 and that corn feedlot cattle bred the infection. So what does medical science do, it tests something else (grai n and injects e 157, via cannulas into the gut instead of allowing the mutation to occur like it does) against hay (which you obviously don’t know is not the same as living grass) and this ‘disproves’ absolutely nothing .

    Where was the grass comparison with the corn feedlot in the study? So again, medical science tests the hypothesis it wants to prove by doing something different. This is how medical science supports its artifical construct and because the guys doing it have PHD’s, accolades, etc. they must be right!

    If medical science needs to use this kind of bull to support its position then it’s worse than I could imagine. I can’t actually believe that you guys are training or trained in anything, well maybe you are potty trained?”

    It really isn’t complicated to see, unless you are a complete believer numpty.

    Bobby said ““Health economists have long known that those countries with the highest expenditure on health care do not necessarily have better measurable outcomes.”

    Well that’s ok then, orthodox health care isn’t working and we have the research to prove it so it’s back on your heads and carry on.

  74. sarah007 says:

    Mark Crispy said right at the beginning of this thread “I had been too inarticulate to formulate what is essentially my approach to this blog: to tell the truth. That would appear to be simple enough. Of course it gets down to what constitutes the truth, and whether you can handle the truth.”

    But it’s your kind of truth Chris that is the problem, it isn’t based on much reality, the labs are full of monkeys, the surgeries are full of protocol robots and the nations are not staying well. Just look in every classroom for the number of asthma inhailers, the number of kids with epipens, is the whole of modern society suffering from deficiency in steroids or has the doctor got it very wrong.

    I am not alone in thinking that none of you on this site who are involved in the daily promotion of super woo can handle the truth, you actively conspire to diss anything that shows up how inadequate you are.

    Lilady said “Here is the definition of “grass-fed” according to the USDA:” Wot, hay. Well they are wrong, anyone can see that grass and hay are not the same thing! And how clever are these people!

  75. squirrelelite says:

    @sarah007,

    How many bales of hay have you loaded to haul to the barn or deliver to the feedlot?

    Speaking as someone who spent a fair amount of his summer vacations loading bales of hay on his grandfather’s dairy farm to haul to the barn to feed the dairy cows and later working loading hay mowed from the wild grass growing around the city lake to deliver to the feed lots in a nearby city, hay is grass.

    You can quibble if you like about whether it’s alfalfa or the new first-cut grass from the spring or later second-cut grass (and those are important considerations in feeding the cows), but that won’t turn it into corn.

    And, as that paper you keep bringing up reports, substituting hay for corn won’t clean out the e coli from a cow’s gut either.

    So, instead of spreading more manure on the screen, try stating a position and make a coherent argument in support of it.

    http://www.google.com/products/catalog?q=manure+spreader&oe=utf-8&rls=org.mozilla:en-US:official&client=firefox-a&um=1&ie=UTF-8&tbm=shop&cid=14333046193008222490&sa=X&ei=fUFKT8CVOeOZiAKasbjaDQ&ved=0CKIBEPMCMAI

  76. sarah007 says:

    “hay is grass.” Nope, fail.

    squirrelshit “And, as that paper you keep bringing up reports, substituting hay for corn won’t clean out the e coli from a cow’s gut either.”

    Of course it won’t you lumpty, that’s not what I said. Raw grass is not the same as hay which is dried grass, you can argue as much as you like but bullshit is bullshit.

    If cattle eat their natural diet, which is raw grass, their gut flora does not pervert. E coli 157 h7 is the natural consequence of eating an unatural diet (too rich in starch which corn is).

    Grain is not a comparative substitute, so the ‘research’ LOL, that lilady put up was irrelevant to the debate.

    Careful how you use it and do not strap to body but I am sure you will find a hole big enough!

    http://www.google.com/products/catalog?q=vibrator&gs_sm=12&gs_upl=8459l13983l0l16957l26l18l2l3l2l4l146l1042l11.1l13l0&um=1&ie=UTF-8&tbm=shop&cid=1819831939131895965&sa=X&ei=Nm1KT4SlB8fW0QX-_8SYDg&ved=0CKwBEPMCMAg

  77. Chris says:

    Ignore the troll.

  78. Purenoiz says:

    @squirrelelite

    Regarding troll007, I work in the natural foods industry. There are many people like the troll who take a gattling gun approach, or like today a shotgun approach to making an argument. They never stick to one thing long and try to change the conversation.

    To begin Mark Crislip stated.

    [quote]I am going to limit myself to the 100% fantasy based wackaloon SCAMs offered by institutions who really should have known better. But that’s me. I do not think popularly and profit should trump truth and integrity. Shame, I guess, is not a concept embraced by our ‘top’ medical centers.[/quote]

    And somehow the troll changed the conversation to e.coli and grass fed beef. She refers to science as a religion*, and then shows that her faith in natural trumps all. In effect she is bound to her beliefs about the natural foods industry and it’s “enemies”. I’ve worked in that industry for 10 years now. From my experience, from retail to outside sales, popularity and profit trump truth and integrity. Troll007 either works in the industry or is a blind consumer, I’ve run into her type so many times where they make incoherent arguments while sincerely believing that they make sense. They love to argue, but can’t stay on topic, and as such should not be fed attention. I’ve referred to them as psychic vampires in the past. They are annoying to say the least.

    *ORIGIN Middle English (originally in the sense [life under monastic vows] ): from Old French, or from Latin religio(n-) ‘obligation, bond, reverence,’ perhaps based on Latin religare ‘to bind.’

  79. sarah007 says:

    Purile said “?” Quentin Crisp said “!”

    Remarkable really, you both have missed the point either deliberately or because you are too stupid to read a post, grasp the point and either add something or move on.

    What is so difficult, raw grass is not hay, corn is not grain, injecting shit into a cannulla tube that passes throught the gut wall into the gut is not the same as eating!

    You must have such a blind faith in the crap you are quoting that you are incapable of reading it and seeing that the conclusion bears no resemblance to the reason for the study. Religion?

    As I have said before medical science + banana = pineapple. Hooray for Noddy and that proves the conclusion because it was approved by very important people who have a degree or phd!

    Weapons of mass distruction rings a bell hear boys.

  80. weing says:

    @squirrelelite

    I agree with Chris. You would have to sink to the troll’s level of lying and stupidity. It’s obvious she has much more experience at that level than you. You won’t stand a chance.

  81. windriven says:

    @Chris and squirrelelite

    I’ve never been particularly fond of the idea of blocking trolls but might be persuaded in the current instance. It isn’t the poorly formed, ill-considered positions or the sub-literate presentation that irks me, it is the sheer volume – as if horse dung smells better when applied in large quantities and is spread over a vast area.

    Makes me think of Greeley, CO once noted by a resident and friend of my father’s to be “a town of broad streets and narrow minds.” Greeley is (or at least was 40 years ago) surrounded by stockyards. Whichever way the wind blew, it was always the wrong way.

    I digress. The powers that be are unlikely to ban the troll so it is incumbent on the rest of us to ignore it, to refuse to engage it, to let it vent its delusions in a great eruption of intellectual flatus, and to do our best to ignore the lingering odor. I’m told that applying Vicks to the upper lip helps a bit.

  82. weing says:

    @windriven,
    “The powers that be are unlikely to ban the troll”
    I think you are right. There is no way that it would be able to spew its so-called “Devil’s Advocate” detritus on Mercola’s site or other SCAMster sites.

  83. ConspicuousCarl says:

    sarah007 on 24 Feb 2012 at 8:32 am

    Mark said “I have always liked Richard Dawkins metaphor of science as climbing a series of peaks (at least that is how I remember it, having read the book years ago). Get to the top of one peak, and it provides a vista of understanding, but there is always another peak to climb to offer an even more comprehensive view of the topic. Every year our understanding of reality is refined and extended.”

    This is very revealing, this idea of peaks and a bit more understanding is hardly scientific, if we taught people to fly planes like this there would be far more crashes.

    That’s how airplanes were invented, and there were a lot of crashes while people tried to figure out if and how heavier-than-air flight could work.

    We avoid crashes during training because, praise science, we don’t have a lot of amateur pilots who constantly assume that everything in the flight manual might just be a conspiracy by Big Aeronautics and instead assume that airplanes fly on wishes and hand-waving.

    But maybe you have another theory. Maybe you think Leonardo da Vinci sat down one day and designed a perfect airplane and wrote a perfect training manual to go with it, and that is the same set of blueprints used to construct stealth bombers.

  84. Chris says:

    windriven:

    I’ve never been particularly fond of the idea of blocking trolls but might be persuaded in the current instance.

    I did not say “block”, I said “ignore.” We have tried to reason with Troll007 (I love that term, Purenoiz!), but to no avail. She is presently in spam mode, since she just posted a couple of comments of a thread that died almost two months ago.

    On this blog it has been noticed that trolls tend to go away if they are starved by being ignored. Though for some it is illustrative to point out their most egregious comments (“toddlers know to stay on the safe sidewalk”), and tactics (like today’s spamming, and subject changes).

  85. windriven says:

    @Chris

    I did not say “block”,

    No, I did. I know you haven’t advocated that and apologize if I left that impression. I don’t really advocate it myself because it is a slippery slope. Once you block a truly obnoxious jerk it becomes easy to block a jerk and then it becomes easy to block someone who poses uncomfortable questions and …

  86. windriven says:

    @weing

    “There is no way that it would be able to spew its so-called “Devil’s Advocate” detritus…”

    How true. On several occasions I’ve written thoughtful comments worded carefully to not be inflammatory on one or another of the anti-vax sites. These comments had the lifespan of a fruit fly. It says a good deal about how insecure they are, don’t you think?

  87. mattyp says:

    A smarter man that me once said this:

    “Never get into an argument with a mug. They’ll drag you down to their level, and then beat you with experience…”

    Think about it.

  88. windriven says:

    @Carl

    “That’s how airplanes were invented, and there were a lot of crashes while people tried to figure out if and how heavier-than-air flight could work.”

    Pearls before swine, buddy. Never try to teach a pig to sing. It wastes your time. And it annoys the pig. And then the rest of us are kept up all night with the pig’s incessant squealing and oinking.

  89. squirrelelite says:

    @Purenoiz, Chris, windriven, and weing,

    I agree that the best approach to commenters like troll007 is just to ignore them. I try to address my comments to the other reasoning commenters and curious lurkers.

    Unfortunately for the natural food crowd, it is rather difficult to provide a continuous supply of freshly growing grass yearround in Ohio or even Kansas.

  90. ConspicuousCarl says:

    @windriven…

    I couldn’t help it. I should know better, but I have a big mouth and the pig was begging to be cooked and eaten.

  91. luarky says:

    rork:

    Maybe it is time to take “integrative” away from the quacks

    *agree agree agree*
    The thing to think about is not so much What is Wrong with Alt-Med – but what is wrong and lacking with science-based medicine.
    Because sometimes people go to alternative medicine because of valid criticisms of how they were treated by “science-based” medicine.
    You can play the game of beating up on alt-med forever, but it will keep on as long as those criticisms remain valid.
    I’ve seen “integrative” doctors a few times – not knowing that was what they were. But as well as a lot of BS and maybe-BS, I got useful things from them. What were they?
    One non-integrative allergist I saw gave his patients a hypoallergenic elimination diet/food challenges process, as part of the new-patient packet. He’d gotten this from an “integrative” allergist. Who happened to be a low-carber, and maybe that’s why his elimination diet was gluten-free. This was before it became known that celiac disease (a kind of gluten intolerance) actually occurs in about 1% of people, rather than in 1 in 5000.
    This elimination diet was *crucial* for me. I probably have celiac disease, and it would have been best if I’d gotten tested for it before doing the elimination diet, because you need to be eating gluten to get tested for celiac disease, and it would have made me feel very sick physically and awful psychologically to go back to eating gluten after the elimination diet. So it was a crude approximation of the right thing to do, but still VERY helpful.
    Another “integrative” gynecologist was brave enough to talk to me about something very embarassing that my non-integrative doctors hadn’t. It helped me.
    Other criticisms:
    Non-integrative doctors tend to ignore problems for which they don’t have a lab test. If they have to rely on how you feel, that’s out of their comfort zone. One example is the elimination diet/food challenges process, which depends on self-observation. Doctors really should be looking out for problems that might be symptoms of delayed food allergies, and suggesting elimination diet/food challenges when that might help.
    Another example – I went to a family doctor for a mysterious chronic bleary state. She did a lot of lab tests, including some tests for nutrient deficiencies. None of the nutrients were deficient. I had the impression she’d covered the bases so far as my diet went, until I saw another doctor, and he suggested it might be some other nutrient deficiencies – for which there aren’t good lab tests!
    The first doctor SHOULD have suggested that I try taking supplements of those other nutrients, just in case. Even though there wasn’t a lab test. But she was thinking in term of “what can I do with lab tests?”, not “what might be wrong?”
    It didn’t turn out to be a nutrient deficiency – but this showed me a problem with the “science-based” thinking.
    Non-integrative doctors tend to think patients are making things up or being hypochondriacs or manifesting a psychological problem, when they have some problem that’s not well understood by medicine. People with CFS for example tend to get a lot of this. Sometimes they don’t understand how much is NOT known. There is often a hubris that goes along with being “science-based”.
    It’s probably a *huge* problem with the “science-based” doctors, not keeping up with research in their field. I had this painfully illustrated to me, with my chronic bleary state. It turned out to be from multiple causes, one was inhalant allergies, as I verified by doing careful experiments by going to live in a clean atmosphere, then exposing myself to suspected allergens. I got allergy skin testing and it had become negative! I used to have skin reactions to almost all the things in the allergy testing.
    I’d seen a couple of allergists and they rather discouraged me from thinking it was allergies because of the negative tests. But I looked a lot on Medline and I found that it’s well-known that people (and animals) can have local allergies, and it’s not uncommon.
    Some delayed food allergies might be local allergies in the gut, although the best-researched example seems to be local allergic rhinitis – local inhalant allergies. Probably what I have.
    There’s been a lot of research over the last 10-15 years supporting the existence of local inhalant allergies, with negative skin and blood tests. It seems particularly to happen with chronic exposure to allergens, part of the tissue changes from chronic inflammation involve generating IgE locally.
    Neither of the allergists I saw were aware of this! I asked one doctor, “can I have this allergy with negative skin tests?” As if asking him for permission!
    He muttered some things, looked embarassed, and finally said “No”.
    I was really shocked to get a look at the dirty underbelly of the reality of doctors.
    This too pushes people towards alternative medicine, when the “science-based” doctors aren’t familiar with new research. When they can find out more online from other patients than from their doctor, this destroys faith in the doctor. They then go looking for info from other places besides their doctor, including dubious “alternative” sources.

  92. weing says:

    “The first doctor SHOULD have suggested that I try taking supplements of those other nutrients, just in case……..”

    Why?

    “…..It didn’t turn out to be a nutrient deficiency – but this showed me a problem with the “science-based” thinking.”

    OK. So the doctor was correct and this is a problem because…?

  93. Chris says:

    luarky:

    The thing to think about is not so much What is Wrong with Alt-Med – but what is wrong and lacking with science-based medicine.

    You must be new here. How could you have missed Dr. Hall’s article on rethinking the annual exam? Or Scott Gavura’s article on drug interactions? Both of which are still listed in recent articles. There are many more that were done over the years including:

    Generic Drugs: Are they Equivalent?
    Reducing the Risk of Adverse Drug Events … and many others under the “Pharmaceutical” category.

    Tonsillectomy Indications and Complications
    The Safety Checklist
    The continuum of surgical research in science-based medicine … and many others under the “Surgical Procedures” category.

    And there are several others. In short, nothing is immune from criticism on this blog. The difference is that it is based on science, not anecdotes.

  94. Mark Crislip says:

    It often seems to me the problems voiced with science based medicine is more the individual doctor, who does not, for a variety of possible reasons, live up to the expectations of an individual patients needs. luarky seems an example of that; It is a given series of docs could not deal with my unique/individual complaints, which is not an inditement of the process of using science to understand human maladies and their treatment. And, for issues like CFS, so far the process is refractory to a good understanding.

    The problem with alt med is more the underlying conceptual framework: it is often wackaloon nuts. The individual providers, however, are fine and have answers within their wackaloon framework.

  95. pmoran says:

    Sarah007Bobby said ““Health economists have long known that those countries with the highest expenditure on health care do not necessarily have better measurable outcomes.”

    Well that’s ok then, orthodox health care isn’t working and we have the research to prove it so it’s back on your heads and carry on.

    I said that, not Bobbyg.

    It also does not at all mean that “orthodox health care isn’t working and we have the research to prove it”. Those populations with poor access to modern health care still have horrendous maternal and infant mortality rates, low life expectations, and appalling burdens of other preventable (using “orthodox” medical knowledge) and treatable morbidity.

  96. sarah007 says:

    Squirrel said “Unfortunately for the natural food crowd, it is rather difficult to provide a continuous supply of freshly growing grass yearround in Ohio or even Kansas.”

    Have you seen the new study by Harvard on feedlot cows producing cancer promoting milk whereas those fed on raw grass don’t.

    The easy answer to the lack of grass is not to bother drinking milk. When it is pasteurised it is almost impossible to digest and get any nutrition out of anyway, it is effectively emulsion paint! If you feed pasteurised milk to a calf it kills it!

    That old myth about milk being a good source of calcium is bull too, there is more absorbable calcium in a small handful of sesame seeds than a glass of milk.

  97. sarah007 says:

    Mark said “It often seems to me the problems voiced with science based medicine is more the individual doctor, who does not, for a variety of possible reasons, live up to the expectations of an individual patients needs. ”

    That is an interesting smokescreen. In England the NICE guidelines tell the doctor what the protocols of treatment are so there is not much room for variation. On the other hand you are dead right about expectations. Most people with BP problems, arthritis, asthma, RA, would expect treatment to mean cure the patient of the disease.

    We all know that the best SBM can do in these chronic cases is buy a little bit of time until the meds kill the patient.

    “The problem with orthodox meds is more the underlying conceptual framework: it is often wackaloon nuts. The individual providers, however, are fine and have answers within their wackaloon framework.” Like there is a pandemic coming and unless you take this meds you will die.

    Considering the lack of patient complaints for alt meds, the lack of political support and national advertising perhaps there is something happening here that you can’t comprehend?

Comments are closed.