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146 thoughts on “Plausibility in Science-Based Medicine

  1. micheleinmichigan says:

    “I sense from discussions with them that even many staunch defenders of CAM know this. They just hate it when we we sneer at CAM or seem to want to lord it over them, especially if seen to be plotting to prevent them from trying anything they wish when they have an unresolved medical problem.”

    I think you hit the nail on the head. Whenever I see a somewhat superior criticism on some harmless (non-toxic) homeopathy or herbal remedy for colds or some other untreatable transient problem, I often feel somewhat defensive (and I’m not a CAM user, generally).

    My gut instinct is, wow, if these guys think $6 for an ineffective cold remedy is bad, I’m not letting them NEAR my make-up bag.

  2. JMB says:

    @micheleinmichigan “My gut instinct is, wow, if these guys think $6 for an ineffective cold remedy is bad, I’m not letting them NEAR my make-up bag.”

    You would be surprised how many things that doctors do in which the amount of income a doctor actually receives is 6$ or less (in the case of medicare/medicaid, somethings we end up paying the government so that we can do them). But the press rages that physician reimbursements are a major factor in the rise of healthcare costs. My income has declined for 3 years, it hasn’t contributed to a higher cost of insurance.

    However, it might be interesting to speculate, if a patient picks up a $6 CAM remedy from a store, then they may delay going to the doctor, and due to the self limited nature of most illnesses, that delay might result in fewer doctor visits, fewer placebo antibiotics, and lower healthcare costs. I guess all we need now is for the USPSTF to use their Efficient Frontier Analysis, figure out what portfolio of CAM remedies lies on the efficient frontier, and then we have the blessing of a government scientific advisory panel so that people will think those efficiently priced CAM remedies are the latest science. Healthcare costs fixed!

    Sorry I digressed. But it is true, if patients get relief from placebo and skip the doctor visit, then maybe that is more cost effective healthcare. There are real pitfalls because delays in treatment can have serious consequences. The only question is how frequently that might occur.

    @BillyJoe “Looking at individual trials is called “cherry-picking”. For every trial they can point to that shows an effect, there is another one you can point to that shows no effect.”

    You’re right. I like the quote that,”frequentists want to be wrong 5% of the time.” From points made in other articles on this site, if you rely on just the p-value, then there is a higher percentage of studies that will fail to show that the CAM remedy is only placebo effect. However, once a weak study gets published in a peer review journal, CAM has got its foot in the door. Then you are left arguing about it in some conference.

    On another issue (perhaps this should be in the Yale symposia or CAM on campus article) the debater sticking to the facts and science wins the science afficionados, and the warmer, fuzzy, feely, sympathetic IM debater wins the less scientifically inclined (even in a medical conference). I wasn’t at the conference, and Dr Novella may have been quite successful demonstrating that SBM is not cold hard detached medicine (the requirements of the doctor patient relationship are just the same whether we are talking about SBM, EBM, or IM). But it is true, as some have suggested in this article, that getting into a rigorous scientific discussion will lose the hearts of some of the audience even in a medical conference, and make the SBM proponent appear colder. That is a tight rope act. I think doctors in private practice face that tight rope act frequently when patients bring up articles they have read on the internet. The response, which can be quite curt based on scientific validity, often makes the doctor appear cold and detached.

    Maybe the SBM advocate could take the talking strategy, “Well, the short answer is, that’s bullshit! I hacked into the email server and uncovered this email from physics to my opponent, that I want to read to the audience….” Insert tm’s letter here…”But on a more serious note, and to address our common goal to do the best we can possibly do for the patient, the long answer is that we know that debate in the scientific community can be confusing, it certainly is to me, but if you spend a lot of time reading all these articles then the best conclusion we can reach, addressing concerns that we all share … … …”, then maybe the presenter might reach both the right brain and left brain people.

  3. BillyJoe says:

    micheleinmichigan,

    “Whenever I see a somewhat superior criticism on some harmless (non-toxic) homeopathy or herbal remedy for colds or some other untreatable transient problem, I often feel somewhat defensive (and I’m not a CAM user, generally).”

    On ther other hand, I get annoyed when practitioners offer up these useless treatments to their patients just becasue there is nothing useful they can give. Why not give them the truth – nothing is going to help your immune system overcome your infection any faster.

    “My gut instinct is, wow, if these guys think $6 for an ineffective cold remedy is bad, I’m not letting them NEAR my make-up bag.”

    Well, you might not need all that make-up :)
    But, apart from the waste of money, there is the further damage of patients trying homoeopathy when it IS harmful, such as a substitute for vaccination.

  4. SD says:

    @JMB:

    “My only formal training in quantum mechanics was about 3 weeks worth in physical chemistry, so obviously I am lacking in knowledge, and was subject to the oversimplification for teaching. Feel free to correct and educate me. I was under the impression that the development of quantum physics came from the search for a mathematical description of a reproducible experiment, the spectra of black body radiation. The mathematical description was plausible because it successfully matched the observed spectra.”

    BBR was one of the big ones, yes. But there were several other contemporary puzzles that were also involved in the development of quantum theory:

    (*) The Stern-Gerlach experiment (quantization of spin)
    (*) The Millikan experiment (quantization of charge)
    (*) The photoelectric effect (quantization of radiated energy)
    (*) Emission lines in atomic spectra (quantization of energy states of the electron)

    There are others, but these are the big ones that come immediately to mind. The history isn’t quite as cut-and-dried as everyone would like it to be, of course, but the creation of a model (“quantum mechanics”) that described all of these apparently unconnected phenomena with a “simple” description was quite the blockbuster.

    The photoelectric effect is one you probably also ran across in P-chem. The puzzle was this: “Why does a photoelectric substance emit any electrons at all when exposed to a radiant flux below the minimum value per unit area that theory suggests is necessary for the emission of a single electron?” (There are multiple ways to phrase the basic question; this is my favorite.) Before the theory of quantization of light was proposed, the energy of the electrons was assumed to be a function of the intensity of the light source; more light == more electron energy, +/-. Beneath a certain level of intensity, there would be insufficient energy to kick an electron loose. This is “intuitively true” – we would expect that the more radiation you throw at a substance that converts radiation to electrons, the more energetic the electrons would be, and that there would be a certain minimum cutoff point beneath which *no* electrons could be produced.

    Well, experiment proved that that wasn’t quite so. The answer, we now know, is that light is emitted in discrete packets (photons), and that intensity means precisely bugger-all in terms of electron energy levels; I can irradiate a photoelectric cell with a lamp all I want, but if it isn’t emitting photons of the right frequency, I won’t get any electrons to show for it, because none of them will be kicked loose to flow through my circuit. In other words, it doesn’t matter how many photons there are per unit area, it matters how many are captured and what their energy level is. This was not believable at the time. That’s why Einstein was so awesome – he was able to explain in a way that it *was* believable, and tied it to other experimental results that buttressed his case.

    “The implausibility came from the interpretations of the equations, and the corollaries of the theory.”

    This is true. There is a deeper implausibility involved, though – the laws of physics before the Quantum Age (hah) all involved an assumption of continuity, i.e. that certain mensurable physical phenomena (electric charge, radiant flux, internal energy, &c.) could take on all values along a continuum. (Another phrasing: “these measurement scales were of cardinality aleph_1, i.e. were of cardinality equivalent to the real-number line.”) That this isn’t the case is not immediately obvious, and not immediately believable. Why should it be? Sez who?

    Well, sez God, apparently, and Fourier et al. “Quantization” arises from the simple fact that when you whack a differential equation with a boundary condition, a quantum number falls out of it. The basic models used describe in detail how this works – rigid rotor, particle-in-a-box, &c. Since essentially all physical phenomena are modelable using differential equations – wave equation, heat equation, and potential equation being the big ones – imposing those boundary conditions produces a wide variety of quantum numbers. (See “eigenvalue” and “eigenfunction” from your P-chem classes for a refresher on how this works.) Those numbers are countable, i.e. have cardinality aleph_0 (equivalent to the natural numbers). Thus, “quantization”. This is all just mathematical fun and games; the science comes in when you observe that the real world behaves the way your model says it does.

    (Note that in other scientific disciplines – fluid mechanics and derivatives – the continuum hypothesis is explicitly assumed for the purposes of mathematical modeling. Without that assumption, the equations fall apart.)

    “So I think quantum mechanics passes the test of plausibility that is being recommended by SBM (your corrections welcome here, I will always be a student).”

    Well, whether it passes the test of “plausibility” or not, it is observed to be true. You can disbelieve in it all you want, but the first time you fire up your DVD player, or use your computer, you implicitly admit its truth.

    “But the key concept here is not that quantum mechanics sounds implausible when we try to describe it, but that the development of the theory was based on plausible explanations of observable phenomena. Of course, maybe that is just the oversimplified version.”

    You’re looking at this through the lens of an age where the fruits of this scientific inquiry are abundant. The plausibility didn’t exist beforehand. The plausibility only existed once it began to predict things that were later discovered to be true by experiment. *Now*, QM is plausible; in a world of semiconductors, LEDs, WiFi, lasers, automated spectroscopes, and the like, it can’t be anything else. At the time, though, QM was weird. I mean, really – in all this big, bad universe, the energy states of the electron in the hydrogen atom can only take on a few values? SRSLY? Sez who?

    Well, apparently… yeah, really. Sez God. SRSLY.

    “Unfortunately in medicine, the application of the arguments of rigorous limitations of scientific validity opens the door to quackery (because we really know so little).”

    It is this simple admission that is so lacking on this blog. Describing the world as it is and sticking to your guns when you have some data to support your opinion is one thing; it is another entirely to pompously bloviate about what is and what “simply cannot be” true based on your scienciness. (And, as previously noted, “statistics != science”, particularly statistics of the type favored in medicine.) The true scientist is always ever-so-slightly unsure of himself, just that tiny little bit hesitant to make absolute pronouncements. “Well, it *seems* as though this is the way the world works…” is as far as the wise scientist will ever venture, long experience having taught him the value of humility before God’s Creation.

    “I think SBM definitely needs a multidisciplinary approach to counter the limitations of college level science education. But we also need to keep an eye on the distinction of whether we are talking about medical science, or medical practice. In medical science we must deal with what is theoretically possible. In medical practice, we must deal with what is theoretically likely.”

    This is another distinction that is so lacking here – medicine as practiced is *art*, not *science*. The day may yet come when it *is* a science, all the hidden mysteries and invariant principles of the human body elucidated, and doctors, with knowledge of the human body to the smallest detail, shall be able to cure any ill, the failures of which cures result from physician error only. That day is not today. (And tomorrow isn’t looking good, either.) Until that day comes, it isn’t a science. It is, at best, educated guesswork. Very good guesswork, yes, but still guesswork.

    Here’s a motto you might meditate upon, on the topic of medical science: “To the extent that it is medical, it is not science; to the extent that it is scientific, it is not medicine.”

    “schroedinger’s children”
    -SD

  5. micheleinmichigan says:

    BillyJoe – “On ther other hand, I get annoyed when practitioners offer up these useless treatments to their patients just becasue there is nothing useful they can give. Why not give them the truth – nothing is going to help your immune system overcome your infection any faster.”

    Yes, Ditto on practitioners. I think I am making a mental distinction between a medical practitioner who sells something, knowing it is useless and a company that sells something knowing it is useless. In the U.S. (I don’t want to speak for folks outside the U.S.) we have a somewhat savior fare attitude about companies selling useless things. Gee, it’s what our economy seems to be based on. (And of course everyone has a god given right to own as much useless stuff as they can afford.) I do hold doctors and other medical practitioners to a higher standard, though. (Lucky them.)

    “Well, you might not need all that make-up :)”
    debatable. ;)

    “But, apart from the waste of money, there is the further damage of patients trying homoeopathy when it IS harmful, such as a substitute for vaccination.”

    Yes! And actually that’s one reason I’m such a big supporter for universal health care in the U.S. Because I’ve known quite a few people who were employed or contract uninsured and try to self-treat to avoid an expensive office visits. Actually one incident warned me off this method when I was just out of college.

    A friend told me how he had taken an “herbal remedy” for a case of giardia that he had picked up on his summer job counting spotted owls out west. No insurance, no money for a doc, no free clinic available, so when his friend, who was an herbalist, offered this remedy with a rational that it was some native american, etc. he took it. He ended up vomiting (black) for a couple days and then still had to go to the doctor for the giardia. My secondhand lesson. The FDA is a beautiful thing.

    That is not the issue with vaccine though, since they are (legally) universally available for children in the U.S. That discussion always end up with education, regulation, and public service announcements. I can not see a day when someone isn’t trying to scam the public in some harmful way, all we can do is try to minimize the effects.

  6. Fifi says:

    I have another suggestion for an SBM specialist to blog here – you’d be doing womankind a great service – an SBM dermatologist! Nowhere are woo and pseudoscience more plentiful, nor more aligned with CAM, than in the world of beauty products. From the expensive skin creams made from placenta of the almost extinct mountain lemur and ground diamonds that promise eternal youth to the extensively marketed lipsticks and lash extenders with added superfruit antioxidant of the moment, it’s an orgy of magical pseudoscience and false promises.

    Don’t get me wrong, I enjoy the drag and artifice of being a woman (and appreciate a good concealer). There’s nothing integrally wrong with makeup, it can be great fun when used creatively and can, when used skillfully, create the illusion that we’re a bit more beautiful than we are naturally. However, the amount of pseudoscience around beauty products certainly puts them in the same category as CAM when it comes to truth in marketing, promoting pseudoscience and irrational beliefs and so on. Most of the cost of a beauty products isn’t the product itself, it’s the marketing and packaging (the cost of perpetuating the con). So, for the love of womankind, please consider hiring an SBM dermatologist who can take on some of the untruths of the beauty industry (though dermatology seems to be a specialty that’s prone to falling off the deep end itself so that may be easier said than actually done).

  7. micheleinmichigan says:

    “Most of the cost of a beauty products isn’t the product itself, it’s the marketing and packaging (the cost of perpetuating the con).”

    Yes. My old company once did a site for a start-up cosmetic company. They were very open with us that they (and many, many cosmetic brands) bought their product from a mass distributor. In many of the cases the content of the bottle is the same, with maybe a small variation in scent. It’s only the marketing and packaging that matter.

    From a personal standpoint I’ll say, if you like make-up and have allergies and you find a brand that doesn’t make your eyes swell-up, cause hives or give you a migraine, stick with it.

  8. micheleinmichigan says:

    That said, I don’t feel a need for medical intervention in my cosmetics, aside from testing for harmful substances. I think most folks know to take the claims with a big ole’ grain of salt. I can not imagine that my wrinkle cream is a gateway drug to some sort of alternative cancer treatment SCAM.

    But then I never believed pot was a gateway to crack either.

  9. Fifi says:

    michele – Considering just how lucrative the beauty industry is, I’d say that most women like to believe and say they don’t believe the claims but that their dressing tables and bathroom cabinets reveal that this isn’t so. Much like the Big Supplement, the cosmetic industry can get away with promoting pseudoscience and making health/beauty/medical claims that aren’t reality based (and often with the “dermatologists recommend/tested” type of pseudo-medical claims or magical ancient zombie placenta type ones so familiar from CAM).

    Since dermatology is a medical profession and women pick up all kinds of erroneous ideas about anti-oxidants, vitamins and various other things from cosmetics marketing – and the beauty industry does sell “health” or the illusion of health/youth/vibrancy – I’d love to see an SBM dermatologist actually take on the woo both in the beauty industry and within dermatology. Clearly women are interested enough to spend massive amounts of their income on beauty products, surely clearing away some of the delusions and lies would be performing a public service. Why wouldn’t someone want to know what was worth the money and what wasn’t? What actually works and what doesn’t? Like with CAM, it’s not like you or anyone else has to stop using the products simply because the truth comes out about them. And like with CAM it’s about giving people the basic information to make informed choices rather than letting an industry abuse science, perpetuate pseudoscience and intentionally feed and exploit people’s desires and fears about basic human facts of life (aging, death, attractiveness, happiness, etc).

  10. Fifi,

    You might like the Paula’s Choice website. It’s commercial, but it’s as close to science-based dermatology as anything I’ve ever seen.

    http://www.cosmeticscop.com/cosmetic-ingredient-dictionary.aspx

    But what I really want is to know the TRUTH about the easy trick to eliminating age spots that I am sure that Big Cosma is hiding from us so that we will buy lots of concealer. Even Paula isn’t forthcoming with the TRUTH.

  11. micheleinmichigan says:

    “Much like the Big Supplement, the cosmetic industry can get away with promoting pseudoscience and making health/beauty/medical claims that aren’t reality based (and often with the “dermatologists recommend/tested” type of pseudo-medical claims or magical ancient zombie placenta type ones so familiar from CAM).”

    Okay, if you insist we have a cosmetics SBM blogger, can it be Tyler Durden?

  12. [a propos of nothing in particular, just a niggling]

    David Gorski on lizkat = pec
    02 Mar 2010
    Actually, Kim Atwood caught it. I simply verified it.

    Diane Henry, Harriet Hall and David Gorski caught it in early February!

    http://www.sciencebasedmedicine.org/?p=3638#comment-41523
    # Diane Henry 02 Feb 2010 at 2:42 pm
    Lizkat = pec? The same “how can we possibly know if these people were actually helped by teh drugz?” that pec always dragged around.

    http://www.sciencebasedmedicine.org/?p=3638#comment-41656
    # Harriet Hall 03 Feb 2010 at 7:15 pm
    The idea that one would want to live only in case a better treatment came along does not correspond to reality. In fact, it reminds me of certain discussions with pec before she was banned.

    http://www.sciencebasedmedicine.org/?p=3638#comment-42015
    # David Gorski 07 Feb 2010 at 11:08 am
    [Y]ou remind me very much of a commenter here who said similarly uninformed pseudoskeptical nonsenses, namely pec. Remember pec? Your comments are bringing back memories of pec.
    I wonder…
    Although your IP address is not the same as pec’s, it does resolve to someplace a mere 30 miles from where pec’s did.

    http://www.sciencebasedmedicine.org/?p=3638#comment-42020
    # lizkat 07 Feb 2010 at 12:52 pm
    I don’t know what pec is or what that has to do with my ip address.

  13. micheleinmichigan says:

    Alison, hehe (that’s my evil chuckle). It may be a propos of nothing, but also oddly satisfying.

  14. tm says:

    Lawrence C: Well, I can’t take credit for the idea. Google for letters to homeopathy from “Science”. And Science is a much nicer guy than Physics will ever be.

    Physics has more than its fair share of cranks. You know the ones purporting to have theories that prove “Einstein wrong”, perpetual motion/energy ideas, or other nonsense. Part of it is the poetry by which the abstract theories are boiled down for consumption by laypeople. But I think the other part is that association with our common beliefs on “genius”. After all, you say, “genius” and the popular mugshot that’s displayed is likely Einstein’s. And if not Einstein, perhaps Feynman. Physicists do share some blame in this. Physicists like that they are part of an exclusive club that has among its members people who are considered geniuses. It certainly does not dim physicists’ well known penchant for declaring themselves smarter than everyone else. (The joke goes that the “kan” is the unit of humility and thus Millikan was well named…) Physics strives to understand the most fundamental processes of the universe. Pretty heady stuff there. Who doesn’t want to have their ideas associated with some grandeur and genius?

    The other reason cranks go after physics more, rather than, say, chemistry or mechanical engineering, is the story of QM’s development and the emphasis on its “revolutionary” impact on the field. The story cranks hear is that QM was a fringe field, sidelined by the mainstream until it finally proved itself correct and upended centuries of physics leading to a new world order within physics (thank you Thomas Kuhn). Of course, QM’s development wasn’t quite like that. Its developers were not some fringe group. Certainly some old guard never wanted it, but most accepted it since there wasn’t a better way to explain what experiments were clearly showing. It took a relatively large group to develop QM, not a single genius. And we didn’t abandon classical physics (otherwise I wouldn’t have had to spend a year long course earning poor grades on it), as no one sane wants to do an inclined plane problem using the mathematical tools of QM.

    CAM fixates on physics for many of the same reasons cranks do. It provides a veneer of genius struggling against a supposedly conspiracy of doubters, by boiling down QM’s history into the Cliff’s Notes version. They also tend to conflate Einstein (a staunch QM opponent) and his special theory of relativity with QM. And if you hear them refer to his job at the “lowly” patent office, you know it’s part of the “lone genius” narrative.

    What you’ll never hear from them is what you’ll hear from physicists who are talking about the state of their respective fields. My school had a great seminar class, where each week a professor from a particular field would go through the same routine: Trot out the Standard Model, and tell us all how it’s broken, and what their work is in fixing it. One professor told us with glee that we really don’t know what mass is. Science sees opportunities in its broken theories and holes in explanations. Generally because this is where Nobel Prizes are minted. But at a less cynical level, scientists truly enjoy the mysteries and trying their hand at chipping away at it and illuminating things a little bit more. Most physicists, if you ask politely and privately, will readily admit they are not geniuses who will go out and rewrite the Standard Model. But being able to find the next piece of the puzzle is what keeps them going.

  15. JMB says:

    SD, thank you very much for the education. SBM is a great site not only because of the quality of the articles, but because of the quality of the discussion threads.

  16. SD says:

    @Dr. Atwood:

    “As usual (I am probably the only SBMista to think this) your arguments are compelling to a point.”

    Aw, stop. You’re *embarrassing* me!

    “The short answer is that “implausible” doesn’t mean “impossible,” although in the case of homeopathy it is very close.”

    True. On the other hand, the greatest gift to the scientist is doubt.

    “Consider: even if your scenario of self-replicating “water shells” were possible, how would they “know” to be the correct ones?”

    Neat semantric trick I played on you – “self-replicating”. Not to beat the musings about homeopathy to death, of course – I already spent my five minutes this year musing about how some bullshit *might* work, a sort of annual tithe to the Gods of Scientific Wonder I like to indulge myself in – but I’d envisioned some sort of metastable congeries of water molecules whose “surface” (a term used loosely) provided a scaffold where other water molecules might be able to assemble into a copy of that shape, mediated by hydrogen-bonding effects. (The clever reader will identify this as an aqueous analogue of how prions are hypothesized to operate.)

    This would be akin to hitting the jackpot seventeen million times in a row. I bring it up only to demonstrate to some of those in the audience (BillyJoe et al.) the kernel of *real* scientific thought: “What if…”

    “Homeopathy isn’t only infinitesimals; it’s, well, homeopathy: like cures like (for which there is also no evidence, BTW).”

    Now we’re at six minutes. I’m going to have to not think about craziness all next year because of this, you know.

    I didn’t say there wasn’t a heaping helping of bullshit involved – my favorite rebuttal to the concept of “like cures like” was to tell a homeopath to drink a bottle of Everclear, then offer him a shotglass full of water with a drop of Everclear added to “cure” the forthcoming alcohol poisoning – just that the concept of repeated dilution did not necessarily violate the laws stated (2nd law of thermo, mass action), and that there were conceivable modes of action for diluted solutions that were scientifically plausible. (Note that I’m going to draw the line at putting a drop on a sugar pill and claiming that it still works, because that’s a little crazier than even I can think about without snickering.)

    “What about all the other stuff in the solution?”

    What about it? I dunno, dude. We’re discussing dreams about bullshit; I can’t answer every hypothetical. Perhaps some substances act as catalysts and others as poisons? This is the level of inquiry where you try to make water shells and see what happens.

    “Getting back to “water shells,” how would they “know” to respond to further dilutions by increasing (not merely maintaining) their numbers (or size or something) according to the number of dilutions, as is required by “potentization”?”

    Back to that semantic trick – “self-replicating”. If I drop one bacteria in a growth medium, it will replicate until there’s no growth medium left; if I select one bacterium from the resulting soup and transplant it to a *new* growth medium, it will do the same thing.

    “Kind of the opposite of what information theory would predict, no?”

    Ehhh… maybe. But I am not entirely convinced of this. Recall that cellular automata (math/CS creations, “artificial life”) have some strange ways to them. The little buggers can be awfully good at replicating themselves.

    Probably the best phenomenon to argue “by analogy” with is supercooling. Science doesn’t get much “harder” than chemistry, and analysis of bulk properties of materials has been done since we developed the means to do it. The freezing point of water is pretty easy to figure out; one of those unexpected little surprises we began to observe when we started measuring this stuff is that water, like many other substances, can be supercooled, reduced below its notional melting point without undergoing a phase change. This is described as the result of a lack of nucleation points within the fluid; sort of like the old Zen koan about the thin string being strong enough to land giant fish because it had no weakest point at which to break, the beaker of supercooled water remains fluid because it has no point at which it can begin turning into ice. That doesn’t happen in the general case – it just freezes, unless you’re careful – but it *is* possible to obtain supercooled water with reasonable reliability. So why is this so? I don’t know, to be frank. My guess is that, were we to examine the water on a small enough scale, we would “see” certain metastable patterns of water molecules (maintained by rotational/vibrational coupling) that, taken in toto, prevent or disrupt the formation of the critical first nucleation center around which the remainder of the water locks into place. I have a sneaking suspicion that these would appear similar to a massive three-dimensional version of Conway’s Game of Life, with similar patterns visible passing back and forth through the fluid; some initial conditions of this game can propagate indefinitely. This can probably be reasonably observed by approximating a statistical model (Boltzmann statistics? I’m not sure, I think the propensity for hydrogen bonding might screw that distro up but good) that gives a distribution of “spontaneous undisturbed freezing times” for a supercooled volume of water at constant temperature T; the model would yield the probability of a subvolume of the water achieving a “magic configuration” that enabled the formation of a nucleation site at any given time t. Any significant deviations from this model or a similar distribution could be taken as reasonable indicators of durable nanoscale effects preventing the formation of nucleation sites, i.e. “water structure”.

    (Note carefully that I am aware that said structure is constantly changing due to thermal noise; think on a slightly larger, “meta”-scale. A group of molecules that passes through a set of states to return to its original state, a sort of “movie loop”, is the picture in my mind.)

    I have a wonderful proof, but the margin is too small to contain it. And by that, I mean I’m tired of thinking about this bullshit. It involves an existence proof and statistical-thermodynamic models of water molecules, possibly with some nice ugly diffusion and convection models thrown in, and I don’t want to. It’s someone else’s turn now. I’m at thirty minutes now, and that means I can’t even think about it for the next six years. >;->

    “(And again, those “shells” that have somehow descended from substances other than what the homeopath was intending had better “know” NOT to get potentized themselves, or there could be some serious drug collisions!) Eksettera.”

    This is the question embedded in the last post – if you didn’t know what you were actually doing, and had (let’s be generous) only a 50% chance of making something that was “active” in the way you wanted it to be, what would the results of a clinical trial of this substance look like? Random noise, pretty much. The fact that homeopaths are idiots, charlatans, or douchebags does not mean that the idea itself has no scientific merit or deserves no inquiry. I dunno about you, but I think it would be pretty awesome to be able to make water do tricks. (And not stupid party tricks like “vaporize and spin this turbine”, either.)

    “From a strictly scientific point of view, the prior probability of homeopathy is very close to zero.”

    No, the observed success rate of homeopathic treatments is not observed to be materially different from placebo in a statistically significant fashion. That is not “the scientific point of view”. Statistics != Science, at least not the bullshit type of statistics used to analyze medical treatments.

    That does not mean that there is nothing to the concept. I have outlined one marginally plausible scientific notion for how it *might* operate. This notion is based on physical principles, is testable though possibly not with current technology, and is reasonably falsifiable, although not completely falsifiable owing to the enumerative nature of the question; one cannot say that there are no possible states in which this might be true, only that one has tested plausible states and found them to not be true. (I exclude without prejudice the possibility that this may be susceptible to proof by enumeration of cases, in a manner akin to the 4-color theorem; if there are a finite and enumerable number of “states” that can be tested, the theory might be completely falsifiable.) There may well be others. Science is about what you see, not what you believe. I see that it is not useful as a treatment; there may be many reasons for that. If I cared, I might be interested in sketching out an experiment to see if there was anything to the idea. I don’t really care. Not A, therefore not B. Hey! How about that. Logic are easy. >;->

    “That it is not zero itself is an acknowledgement of the tentative nature of scientific theory—your plea. But to argue that the distance between zero and the infinitesimal PP of homeopathy—which, in addition to its false premise and molecular problems and clinical trial failures also fails to predict anything in nature—to argue that this is enough to justify medical schools coyly suggesting that it “might” work (see above), amounts to, well, keeping your mind so open that your brain falls out both ends.”

    Do I suggest that they say it *might* work? Not a bit. I suggest that they privately maintain the iota of doubt necessary to claim the title of scientist. Hubris is the death of a scientist. And, like Nasrudin, sometimes contemplating what is on its face folly can lead to deeper Truths.

    “just a fool in a fool’s paradise”
    -SD

  17. BillyJoe says:

    SD,

    “…the laws of physics before the Quantum Age all involved an assumption of continuity… That this isn’t the case is not immediately obvious, and not immediately believable. ”

    Except that the concept of an indivisible unit was hypothesised as long ago as 442 BCE, when Democritus came up with the concept of the atom.
    (ie the plausibility of quanta was nowhere near zero as is the plausibility of homoeopathy)

    “Why should it be? Sez who? Well, sez God, apparently…
    … SRSLY? Sez who?…Well, apparently… yeah, really. Sez God. SRSLY.”

    What? Einstein’s God? Abraham’s God?
    (Are you waxing lyrical or just proselytising? Just asking.)

    “Well, whether it passes the test of “plausibility” or not, it is observed to be true.”

    The plausibility of the indivisible unit is not in question. Of course it is. Entanglement, decoherence, and uncertainty, however, are another kettle of fish. Yes, they have to be true and, yes, they are completely counterintuitive. But they are what we might call the corollaries of Quantum theory.

    “The plausibility didn’t exist beforehand. The plausibility only existed once it began to predict things that were later discovered to be true by experiment.”

    The experiments comfirmed that the plausible but not favoured quanta were, in fact, true. Of course continuity is also true. Photons interact as particles but they travel as waves.

    “it is another entirely to pompously bloviate about what is and what “simply cannot be” true based on your scienciness. The true scientist is always ever-so-slightly unsure of himself, just that tiny little bit hesitant to make absolute pronouncements. ”

    But there is a limit:
    The Earth simply cannot be flat.
    Homoeopathy simply cannot be true.
    Evolution is quite simply true.

    “Well, it *seems* as though this is the way the world works… is as far as the wise scientist will ever venture, long experience having taught him the value of humility before God’s Creation.”

    God being the shakiest of all hypotheses by the way.

    “This is another distinction that is so lacking here – medicine as practiced is *art*, not *science*”

    It is both science and art.
    If I present to my GP with a typical meningococcal rash, he will immediately load me up with penicillin and call an ambulance to transport me to hospital. Science all the way.
    If I present because my father died of prostate cancer, he will inform me of the pros and cons of testing to guide my choice. That is both science and art.
    If I present confused and anxious about my diagnosis of metastatic melanoma, he will empathise with me. That is art.

  18. micheleinmichigan says:

    “one of our most assiduous commenters, Daedalus2u, added a very important point. The data are [...]”

    oh, for a minute I read insidious and thought “Gee, being a bit hard on Daedalus2u” –

    “assiduous” – constant in application or effort; working diligently at a task; persevering; industrious; attentive: an assiduous student.

    good word.

  19. Oh, SD – you’re so cute thinking that “making shit up” is the same as science as long as you use sciency-sounding vocabulary.

    Here, Orac wrote a post just for you.
    http://scienceblogs.com/insolence/2010/03/alternative_science_alternative_medicine.php

  20. anoopbal says:

    I am not sure if you can apply biological plausibility to every situation. It is usually considered as a weak criterion because it is limited by our knowledge.

    If we used plausibilty 300 year back, nobody would have used citrus fruits for scurvy nor people would have believed mosquitoes are linked with black water fever.

    I think it works for some cases and cannot be generalized to every situation. A problem of external validity I guess.

  21. anoopbal on plausibility:

    “If we used plausibilty 300 year back, nobody would have used citrus fruits for scurvy nor people would have believed mosquitoes are linked with black water fever.”

    I don’t understand. Plausibility was used 300 years back to identify citrus fruits as something that might prevent scurvy. They didn’t know what the mechanism was, but it was completely plausible that diet could have something to do with the diseases of sailors on long trips.

    300 years ago Europeans knew that malaria was associated with marshes, though they didn’t know the mechanism. According to Wikipedia, 2,500 years ago South Asians knew it was caused by insect bites, though again they didn’t know the mechanism. Again, they thought it was completely plausible.

    Knowing the details of a mechanism is different from knowing there could be a mechanism.

    Maybe there’s some confusion about what plausibility means.

    ___________
    From dictionary.com:

    Having an appearance of truth or reason; seemingly worthy of approval or acceptance; credible; believable: a plausible excuse; a plausible plot.

    —Synonyms
    1. PLAUSIBLE, SPECIOUS describe that which has the appearance of truth but might be deceptive. The person or thing that is PLAUSIBLE strikes the superficial judgment favorably; it may or may not be true: a plausible argument (one that cannot be verified or believed in entirely). SPECIOUS definitely implies deceit or falsehood; the surface appearances are quite different from what is beneath: a specious pretense of honesty; a specious argument (one deliberately deceptive, probably for selfish or evil purposes).
    ___________

    Thus, to say something is plausible doesn’t mean that we already know everything about it. It means we know only enough to know it could be true. A lot of things could be true, based on what we know, but not all of them are.

    If I tell you that I had eggs for breakfast, that’s both conventional and plausible. If I tell you that I had muskrat eyes for breakfast, that would be wierd but it would be plausible because muskrats exist, they have eyes, and they can be consumed. But if I tell you that I ate a Prius for breakfast, that’s not plausible. (Part of a Prius, yes, but not a whole Prius. It’s just too big.) If I tell you that I ate the theory of relativity for breakfast, that just doesn’t make sense.

    In fact, I had Red River cereal for breakfast, which is just as plausible as eggs and more probable than muskrat eyes. On the basis of plausibility alone, you can’t judge between the cereal and the eggs. You have to perform a scientific retrospective study, come to my kitchen and and discover the pot I cooked the cereal in my sink and no egg shells in the compost and then you’ll be pretty sure.

    Back to plausibility and homeopathy. If you describe homeopathy, it’s not plausible. It’s like me eating a whole Prius for breakfast. It couldn’t happen. If you use quantum woo to justify why you think homeopathy is plausible, then you just stop making sense. Like me eating the theory of relativity for breakfast.

    A lot of stuff in science is muskrat eyes for breakfast. That makes it weird, not implausible. And a whole bunch of stuff in science is just eggs vs cereal.

  22. Fifi says:

    Alison – Thanks for the link, even if it is a commercial site. That’s the problem, of course, skincare and beauty products tend to be a lot like commercial/fad diets, exercise products/fads and (often) CAM in how it’s hard to find sources of information that aren’t busy selling and promoting their own product. That’s why I’d find it interesting – though I may be alone in my curiosity – to have an SBM dermatologist blog once in a while (if any such thing exists!) to actually sort out the real science from the pseudoscience. Not just about makeup and ingredients in beauty creams, but also about general dermatological issues that effect both men and women and to offer a general education about everyday dermatology.

  23. @SD:

    Ah, SD (was that redundant?). No semantic trick, that. I got it awready, including the analogy with bacteria in media, but it doesn’t explain potentization (even if it can explain eu-potency, so to speak). And of course there’s still the problem of specificity. This could go on ad nauseam (costing you lifetimes of not thinking about it), but I put one bacterium into a growth medium, and so on…and each time I introduce one of its progeny into another little vat o’medium, that medium just happens to have, well, several hundred or thousand other species of bacteria already hanging around in it, and…you get the point.

    And (yeah, yeah, the bacteria analogy breaks down here) there’s the problem of how it’s done: dilute, “succuss,” dilute, “succuss,” etc. Succuss=shake’n'whack (wank?) the test tube a bunch of times on a wooden table covered with leather, or some such thing. Bit of chaotic energy (heat) added there, no? In an aqueous solution, not exactly a recipe for enhancing the signal. Doesn’t disprove your “marginally plausible notion” about water, perhaps, but you got homeopathy to explain here, fella.

    (Hmmm: “marginally plausible”)

    By “prior probability,” BTW, I meant “without considering its observed success rate.” (I apologize for not having made that clear, since “prior probability” would otherwise be assumed to be based on all that is currently known). Thus it ain’t statistics I was talking about, at least not the statistics of clinical trials. Your “hitting the jackpot seventeen million times in a row,” well, that’s some statistics that I can get behind, and not so different from what information theory might say about all this, I’d venture.

    Slight change of subject: SD, we get that medicine isn’t science. Please look at some of our earlier posts, from before you started commenting. Here, for example.

    “nothin’ ain’ worth nothin’ ”

    -KA

  24. David Gorski says:

    If we used plausibilty 300 year back, nobody would have used citrus fruits for scurvy nor people would have believed mosquitoes are linked with black water fever.

    Really? Do tell.

    Read the Wikipedia article on James Lind, the military surgeon who conducted the first known controlled clinical trial on scurvy, which states:

    Since antiquity in various parts of the world, and since the 1600s in England, it had been known that citrus fruit had an antiscorbutic effect, when John Woodall (1570 – 1643), an English military surgeon of the British East India Company recommended them[5] but their use wasn’t widespread. Although Lind was not the first to suggest citrus fruit as a cure for scurvy, he was the first to study their effect by a systematic experiment in 1747.[6] It ranks as one of the first clinical experiments in the history of medicine.

    In other words, lots of people found it plausible that citrus fruit somehow helped scurvy at least as far back as the 1500s, but Lind was the first ever to prove it through science. This is a case of anecdotal reports being tested by a controlled clinical trial.

    Since black water fever is a complication of malaria, it should be pointed out that, although Sir Ronald Ross is the man credited with first demonstrating that malaria is transmitted by mosquitoes in 1897, it had been suspected that mosquitoes were somehow linked with malaria, and as early as the early 1700s (300 years ago) Giovanni Maria Lancisi partially linked malaria with mosquitoes from swamps and recommended draining swampy areas to cut down on its incidence:

    The “miasmatic” theory of malaria transmission dates back a long way into history; Hippocrates (460–375 BC) had for example, inAirs, Waters and Places linked the environment with disease.3 The term malaria was in fact derived from “bad air” which emanated from marshes. Giovanni Maria Lancisi (1654–1720), physician to the pope and professor at the Sapienzia in Rome published De noxiis paludum effluviis, eorumque remediis in 1717; although this title indicates that he, like most of his contemporaries subscribed to the “miasmatic” hypothesis, he suggested the possible role of mosquitoes in transmission of the disease.

    So, for a long time malaria was associated with swamps, and some associated it with the mosquitoes living in swamps going back hundreds of years. It wasn’t so implausible then, 300 years ago, that black water fever might have something to do with mosquitoes. Indeed, it has been recorded that certain pharaohs used to sleep under mosquito netting; whether that was for comfort or not it might indicated that the ancient Egyptians knew that disease was associated with mosquito bites.

  25. daedalus2u says:

    I think the idea of prior plausibility should actually be reframed into one of a lack of prior implausibility. It isn’t that one should have reasons to positively think that something is plausible before testing it, but rather that one should not be able to come up with reasons (actually data) why it is fatally implausible.

    For most things it makes no difference. Homeopathy is implausible for many reasons which are easily articulated. Reiki is implausible for many reasons. Magic words are implausible, acupuncture is implausible, virtually the whole CAM compendium is implausible for many well known facts tied together with valid logic.

    There was no data that said that the idea that ulcers were caused by an infection was implausible. An argument that the idea that infection caused ulcers was implausible could not have been made based on facts and logic. The only basis for implausibility was personal incredulity by those who successfully treated ulcers using a non-infectious causation paradigm.

    To say that an idea is implausible, one has to have positive facts and a chain of v alid logic that shows it is implausible. This is a high standard, but I think it is a standard that is necessary if one is to not reject correct ideas before they have been tested.

    If you don’t have facts and a chain of logic showing that an idea is implausible, one does not know if it is implausible or not. The skeptic has to default and say “I don’t know”. A skeptic can’t say something is implausible from personal incredulity.

  26. David Gorski says:

    There was no data that said that the idea that ulcers were caused by an infection was implausible. An argument that the idea that infection caused ulcers was implausible could not have been made based on facts and logic. The only basis for implausibility was personal incredulity by those who successfully treated ulcers using a non-infectious causation paradigm.

    Actually, I always find the ulcer example amusing. Before H. pylori was discovered, it was thought that ulcers were due to things that any CAMster could love, such as stress, which led to too much acid secretion, and diet. Treatments consisted of trying to reduce psychological stress and the use of special diets, first coupled with trying to neutralize the acid with bicarbonate of soda and then later using nasty pharmaceuticals to block acid secretion. Then a real cause of ulcers was found that could be treated scientifically, and all the mind-body stuff about stress was thrown by the wayside and the special diets found to be of little help compared to good, old-fashioned antibiotics.

  27. s_hohum says:

    David Gorski’s mention of scurvy and plausibility brings to mind a wonderful article about scurvy from Idle Words: Since the concept of a trace nutrient was unknown, the cures were discovered, lost, and misinterpreted to the point of uselessness. While Lind’s work enabled the British Navy to essentially eliminate scurvy in 1799, the lack of a biological model for the disease meant that a new formulation of lime juice introduced in 1860 was completely useless, as the ascorbic acid had been lost! No one noticed because steam power made voyages too short for scurvy to develop. It was a terrible problem for the 1911 Scott expedition, 164 years after Lind’s work.

    It’s startling that even a well-documented, effective cure can fail utterly over time if the mechanism isn’t understood.

  28. anoopbal says:

    “In other words, lots of people found it plausible that citrus fruit somehow helped scurvy at least as far back as the 1500s, but Lind was the first ever to prove it through science. This is a case of anecdotal reports being tested by a controlled clinical trial.”

    Hi David,

    I don’t get it. Biological plausibility means it should be biologically believable.

    How can it be biologically believable “lots of people found it plausible that citrus fruit somehow helped scurvy at least as far back as the 1500s”. This is not biological plausibility, this is people just simply believing in anecdotes.

  29. Plausible means believable.

    People know that food has an effect on health. Sailors have limited diets and sailors get scurvy. Therefore it’s believable that food could have an effect on scurvy.

    That’s it. If that’s all you know, then that’s all it takes for plausibility.

    To discover which foods prevent scurvy takes Lind’s systematic experiment, but Lind conducted the experiment because it made sense to do so. It makes sense that food could prevent scurvy, so it makes sense to conduct tests to find out more.

    Acupuncture has some plausibility, because it is an action on the body. That’s why there has been so much interest in testing it. It needed to be tested because we didn’t have enough information to know if it worked. It’s been tested and found wanting.

    Homeopathy just has no plausibility at all. We need to test it like we need to conduct tests to see if the world is a flat disc resting on a turtle.

  30. pmoran says:

    “There was no data that said that the idea that ulcers were caused by an infection was implausible.”

    There was. Researchers had already looked hard for, and been able to demonstrate bacteria in the ulcers themselves. This was early last century when syphillitic and tuberculous ulcers were still fairly common.

    Even after I confirmed the presence of H pylori in my own duodenal ulcer patients on gastric antral biopsies, it was not clear how a diffuse bacterial infection of the stomach caused separate ulcers in the duodenum, or why measures directed at acid production (surgery and drugs) should be curative of most ulcers.

    I personally only became convinced of the bug’s role in causation of ulcers after long term studies from multiple different centres showed that intense antibiotic treatment could produce long term cure of ulcers. That took time.

    The early treatment regimes were also fairly arduous for the patient with significant risks (e’g’ antibiotic-associated colitis), so I was in no hurry to try them out on my patients before the results were securely in.

    There were a lot of unusual elements to the H Pylori story. It is by no means a simple example of doctors being overly conservative.

  31. micheleinmichigan says:

    “Homeopathy just has no plausibility at all. We need to test it like we need to conduct tests to see if the world is a flat disc resting on a turtle.”

    just to be an annoying stickler..er – quoting from the original article. “Having said that – even the most implausible claim can still prove itself with sufficient clinical evidence. If homeopathy actually worked, it could be demonstrated through repeated rigorous clinical studies (something which has never happened).”

    Which make me think of that older movie the Medicine Man (Sean Connery). It’s not the herb that’s the cure, it’s the ants. (The scientist and the doctors all just collectively winched.)

    By the way that’s quite a rich history-ed analogy you are sporting there. The world is a flat disc on a turtle indeed.

  32. anoopbal says:

    “People know that food has an effect on health. Sailors have limited diets and sailors get scurvy. Therefore it’s believable that food could have an effect on scurvy.”

    My question was about citrus fruits. It is biologically plausible for food to affect health but not that plausible for someone to say out of the 100′s of perishable food it was citrus fruits that were the culprit. And I am not sure (nor you) if it was all the anecdotal evidence or the “it made sense to him” aspect that made him test citrus fruits.

    I agree about the generality of your food example, but I don’t think this sort of generalized statement without any biological specifics ( like the beta blockers example) is goona be of any help in nutrition/food science then.

    “We need to test it like we need to conduct tests to see if the world is a flat disc resting on a turtle.”

    And that‘s exactly the limitation of biological plausibility. It is limited by what we currently know. Centuries back our knowledge about earth was limited, and you can’t blame them for believing the earth being a flat disc.

    Just like the Hill’s criteria, each one of them has pros and cons. The importance of each depends on the context. I am not sure why SBM is just so caught up just on the plausibly criteria. Why not add the other criteria’s too?

  33. anoopbal says:

    “The core principle of EBM, however, is that even in such situations we still need clinical studies looking at net health effects to show that plausible treatments are safe and effective – plausibility is not enough.”

    Are you sure?

    According to Sackett who came up with term EBM: “And sometimes the evidence we need will come from the basic sciences such as
    genetics or immunology. And if no randomised trial has been carried out for our patient’s predicament, we must follow the trail to the next best external evidence and work from there”.

    So I am not sure if EBM approach is just about clinical studies.

  34. JMB says:

    When you are discussing a treatment with a patient, plausibility is more an informed decision by the patient from the doctor’s discussion The doctor is presenting their best opinion, the two of you work out what will be done if you do not agree.

    When you are arguing IM in a medical conference, I think the suggestion that the plausibility argument would have prevented the progress in treatment of ulcers simply isn’t a realistic interpretation of history. I also think that the test of plausibility didn’t prevent the development of quantum physics. The test of plausibility certainly didn’t stop the multiple clinical tests of acupuncture. The tests of plausibility didn’t stop the clinical evaluation of manipulative therapy for back pain. There were plenty of politics played with plausibility in the issue of funding treatments by Medicare and health insurers. The argument that we should reduce our reliance on plausibility because of the historic paradigm shifts in science just doesn’t add up when you consider the history of how those implausible ideas were treated.

    When you are arguing plausibility in allocating resources for reimbursement of procedures or funding of scientific studies, frankly our ideas of plausibility take a back seat to the quality of observational studies (which are usually performed without grant funding, and much less expensive than large scale RCTs). I do think it was a political decision that there is now a separate branch of NIH for CAM, but politicians waste our money all the time.

    So arguments over plausibility are mainly an academic argument. I don’t think that calling homeopathy implausible compares at all to calling quantum mechanics implausible. The scientific test of plausibility was not an impediment to the development of quantum physics (blame that on the mathematics and the limits of human intellect).

    @Anoopbal …According to Sackett who came up with term EBM: “And sometimes the evidence we need will come from the basic sciences such as genetics or immunology. And if no randomised trial has been carried out for our patient’s predicament, we must follow the trail to the next best external evidence and work from there”. …

    I do think that there are some in EBM that have deminished plausibility to such a miniscule factor that they tend to use CAM as just another group of therapies that may be used. I am not that well versed on it, the only study I saw from the Cochrane Collaboration that seemed to address CAM was in the treatment of a terminally ill patient (I’m sure others here will give more examples). The Cochrane is just one prominent group of proponents of EBM. It appears to me that proponents of IM are using the diminished factor of plausibility suggested by the formalism of EBM to push CAM treatments into mainstream medicine.

    I do think it is ridiculous for medical students to pay $1500 for a course in a CAM. If I was still a professor, I might suggest that anybody who signs up to pay that much money for the course may need some remedial training in critical thinking. That would be a case where I would pull out the provocative approach to education. I would also make sure that the students understand that they ethically cannot profit for care provided as a placebo effect, so don’t expect to recoup your investment.

    I would be suspicious that there is a new business model for making money from placebo effect, the modern day version of Dr Johns Medicine Show. Get an MD, get a faculty appointment at a prestigious medical school (or a high profile job in the media), and earn a descent (maybe indecent) income from selling books you have written about CAM. It’s like a legal loophole to the ethical position that you should not make a profit from providing a placebo effect.

    @SD I would be interested in your criticism of statistical methods used in medicine. By the way, there are patients that if you told them there was a 1 in 15 million chance they might die from a beneficial treatment, they would not have the treatment. The definition of intellectual honesty in medicine is tempered by considerations of the perception of risk. Our medical practice art taints our medical science.

  35. micheleinmichigan on insurance companies and autism diagnoses (Diagnosis, Therapy and Evidence thread):

    “Their rational is they don’t pay for developmental delays. That it is an educational need (not medical.)”

    Private comment on discussion of education and neurodiversity.

    *** *** ***
    Michelle Dawson’s critique was of the assumption that autistic children need to learn in ways that NT adults feel comfortable with. She was not critiquing the idea that autistic children need to learn. Your examples of interrupting an NT child watching television and an autistic child stimming, in both cases so that they can become available for learning, were examples of interrupting children *not* learning.

    (People who know more about autism might suggest that autistic children who are stimming might in fact be paying close attention to what is going on around them, and that preventing them from stimming might make environmental stimulation too overwhelming and painful to benefit from. But I really only know what I read in the paper — I know that you know tons more about the topic generally and of course about your child in particular. I’m just trying not to be simplistic.)

    I think the “neurodiversity” concerns are that interventions like ABA are supposed to be therapies with a goal of make a child appear less autistic, which makes other people more comfortable but perhaps at a price the autistic person feels is too high.

    I think the “neurodiversity” preference is for educational approaches to help children be the best they can be. For NT children we take for granted that this includes helping them to develop talents for things they enjoy and are good at. When an NT child is particularly good at sports, for instance, we use that to develop physical skills, teamwork, time management and goal-directedness. That child is likely to also enjoy music and dance, which we will also encourage. The kid still has to go to school and if they happen to struggle with any academic subjects we will give them the support they need to do as well as they can, drawing on what they are already good at as appropriate.

    I think the “neurodiversity” concern is that when a child has great autistic skills these are dismissed as being deficits, the child is prevented or discouraged from doing things they enjoy and are naturally good at, and instead is required to practice only things that do not come easily to them.

    I think.

  36. micheleinmichigan says:

    Alison – you make excellent points. Actually, after reading your previous comments and the NTs are weird blog, I was really thinking about different approaches. I think there is an important distinction between changing (curing) what a person is (how their brain came to them) and teaching them skills that they need in life or strengthening the skills they already have. (speech, emotional regulation, social skills, etc.)

    But, I can not set myself up as any kind of expert on autism. I’m sorry if I seemed to be saying so, I didn’t mean to give that impression. I’ve only made observations based on interacting with children with autism and their parents within the preschool/therapy setting that my son attends.

    My son has a speech delay (that is a simplification) that is caused by his cranio-facial differences and possibly early hearing difficulties. Because the anatomy of his nose, mouth, throat are different, even after surgeries, he has needed intensive speech and language therapy. Also, he has no hearing in one ear and develops fluid in both ears which require tubes for him to hear properly in his good ear, so he receives preschool services from our area Oral* Hearing Impaired program.

    So, from a parental experience aspect, I would consider my main area of expertise to be in speech and language problems and delays AND even then I have a tiny fraction of the knowledge that a speech pathologist would have. This probably gives me a real slant in regards to my perception of therapies for children with autism because my whole experience with children with autism and their parents has been through speech therapy or speech/pre-literacy focused preschools.

    Within that setting the focus is generally on teaching and building the best communication skills possible. When it is done well (!), the form of communication and the methods of therapy are tailored to the child and family, meaning an approach that the family can’t possibly afford or maintain should be avoided and parental preference is often a factor when choosing a form of alternative communication.

    Interestingly all the therapists I’ve dealt with, (even the really bad one) always ask about interests and strengths. Generally, if they can use a child’s interest to motivate them in therapy or they can build on a strength it makes it easier on the child AND the therapist.

    You make an interesting point about the stimming as a self-soothing measure that can allow a child to focus on reducing anxiety. When that is the case it would make complete sense to allow, if it is not interfering, or redirect to another self soothing measure.

    This is not an autism example, but my son has a washcloth lovey. He used to enjoy carrying it everywhere. He often rubs it on his face/mouth. The problem, you can’t do good articulation therapy with a child with a cloth over their mouth. :) So we allowed him to have the cloth, in his lap, later the speech therapist would have him give it to me to put in my pocket. Which worked fine with him.

    A good therapist has to always be cognizant of a child’s anxiety or frustration level. To be challenging can be okay, but if a child is pushed to hard, therapy becomes a negative association and that’s just going to make it harder for them to learn. Better too be too easy than too hard, I think.

    This is not to negate any of Michelle Dawson’s (or other bloggers) complaints, only to say that perhaps ST is more focused on teaching, so I was getting an inaccurate picture of the bloggers experiences. Which is good for me to know.

    Outside of the subject of autism, I find myself reflecting quite often on balancing decision making for a child with medical/extra-educational needs. For instance, recently we were discussing having rhinoplasty for my son. His nose is adorable, but it attracts comments from other kids, which he does not like. There are several different answers on how to deal with this (which I won’t bore you with.) But one of the things you have to consider is how much effort/risk/pain should be put into making it easier for him to blend in? How much is societies job to be sensitive and open-minded? How much is his job to learn to handle his difference (with our help)? It can’t be all one sided. It has to be a combination of the three.

    Regarding – the problems with ignoring strength to focus on faults. That is an excellent point. Here is an anedote that reminds me of. I recently was reading a discussion in the online group for parents of children with hearing loss. One parent told a story of how her daughter’s elementary school speech therapist and TOD* repeatedly wanted to schedule the daughter’s pull out sessions for speech and academic support during her music/band classes. The daughter loved music so the parent would refuse and say “you have to work out something else” which they eventually did. Now the daughter is in middle school. She is in the high school orchestra and plays in the community orchestra. She is an extremely talented musician AND she is doing very well in school. Maybe her interest in music and the confidence it generated even helped her academically.

    Anyway, very interesting discussion. Thanks for your thoughts.

    *Oral in this case mean speaking only rather than signing alone or signing and speaking. Our district has a separate program for “Total Communication” which is speaking and signing.

  37. micheleinmichigan on autism intervention:
    “Alison – you make excellent points.”

    I have no idea whether I do or not. I’m paraphrasing what I understand from what I read on the internet. Almost everything I know is second-hand — that is, all I know is what certain other people think — which is why I try to be careful not to make assertions.

    If someone is interested in autistics and autism, for whatever reason, I’m happy to share the resources I’ve collected. But I will always defer to their experience because I just don’t have that experience. For instance, I can summarize a particular critique of ABA, but I have never done or received ABA and I don’t know anyone getting ABA, so if someone says their kid loves ABA and is getting a lot out of it there is no way I’m going to argue — I’m going to ask questions!

    I have various relatives with various ASD diagnoses, but we don’t live in the same countries so I don’t know them well. I have a friend on the internet (http://www.fashion-incubator.com/) who is autistic (and who has an autistic, schizophrenic and cognitively-impaired adult son) and I picked up some of the links on her site and followed them. Because of my own social and brain-related difficulties, some of the neurodiversity discussions are meaningful to me. So while I have various paths to being interested, I remain ignorant in the most fundamental way.

  38. micheleinmichigan says:

    “So while I have various paths to being interested, I remain ignorant in the most fundamental way.”

    Oh well, we will be interested and ignorant together. :)
    One of the things I find interesting in the ND and or physical difference discussion is how it questions the common views on alot of mental/physical difference. How it points out how our first reactions can be essentially flawed and adds a new perspective that you can take to dealing with anybody who may be “not typical” (including myself.)

    cheers
    Michele

  39. JMB says:

    Just a thought.

    We talk about scientific method in medical science. We talk about SBM being a method of analyzing information from medical science, and applying it to medical practice. We also talk about how plausibility is a key concept differentiating SBM from EBM. One of the biggest arguments for plausibility may be in the development of models of disease. Once we have a model of disease (similar to the discussion by Dr Atwood of a model of cancer in the thread of Diagnosis, Therapy, and Evidence), then we can use that model for tests of plausibility. Science works better with a testable hypothesis rather than an argument about theory. A model may allow a quick test of a hypothesis with reported observable data. If a hypothesis fails to account for historical data, then it may be categorized as implausible. Serendipitous discoveries tend to leave much of the previous model intact (relativity did not throw Newtonian physics out the door, it refined it). Arguments that plausibility deters serendipity loses weight when models reasonably encompass past observations. A model for gastric ulcers would have included various known etiologies including syphilitic ulcers even before H pylori became a widely recognized cause (thank you pmoran). The so called paradigm shift would be more correctly viewed as the identification of a previously unknown infectious etiology. Models can also bridge the chasm between medical science and medical practice.

    Ultimately the definition of SBM is made by the high profile physician scientists who write articles and give presentations about it. It may become mostly a skeptical critique applying pressure for more rigorous approach to analyzing medical science literature. It may also evolve into the application of scientific method to the process of review of scientific medical literature, and the translation of that information into medical practice. Developing models of disease, or using existing ones to assess plausibility, may push the idea of SBM into another field of scientific study.

    Given the current state of affairs, it may be more important to keep of the pressure of skepticism on the direction medicine is drifting, rather than to develop a new scientific approach.

    We use a lot of implied models in our descriptions of disease, reliability of reported data, and plausibility. One advantage of making those models more explicit is that those who may argue against SBM can not use their own the description of plausibility as an argument against SBM.

    Plausibility has a language definition, and a mathematical definition ( a priori probability in Bayes approach ). It could have a definition based on a computational model, which provides a fit to reported data (similar to the comment by daedalus2u that the data is always right, it’s the interpretations that change).

  40. RE using scurvy as a model of science-based or evidence-based medicine:

    http://idlewords.com/2010/03/scott_and_scurvy.htm

    Apparently the cure for scurvy was discarded for 100 years after it was found. An alternative hypothesis was found to be more evidence-based than the correct one.

  41. JMB says:

    @Alison Cummins “Apparently the cure for scurvy was discarded for 100 years after it was found. An alternative hypothesis was found to be more evidence-based than the correct one.”

    If a model of disease can be used to evaluate plausibility, then the available data that it must successfully fit has to be comprehensive and reliable. If the information about the previous diet (lemon juice supplement) which had proven successful, and the observations about the length of time it took for symptoms to occur had been available for a model of the disease, then the hypothesis that preserving meat with a different method might have proved successful could have been shown successful.

    Models of disease are by no means a perfect answer for the problem of medical discovery. One major difference between then and now is the massive amount of data now available that might be useful in giving direction to medical discovery. Computational models of disease can organize access to the vast body of information now available from medical scientific literature, much like the PageRank model of google organizes access to information on the internet.

  42. JMB says:

    Bad error in my discussion above! Amend the statement,
    “then the hypothesis that preserving meat with a different method might have proved successful could have been shown successful.”
    to,
    “then the hypothesis that preserving meat with a different method might have proved to be implausible.”

  43. I think it supports what Daedalus’ said about any model needing to fit the data, but the data always being right. The correct hypotheses fit the existing data just fine (there is something in fresh lemons that prevents scurvy). But then new data were introduced (lime juice boiled in copper vats does not prevent scurvy) and an alternative hypothesis was proposed (there is something in tainted meat that causes scurvy, and even meat that doesn’t appear to be tainted is tainted… because it causes scurvy). The old (correct) hypothesis could have been retained and modified (there is something in fresh lemons – but not in lime juice that has been boiled in copper vats – that prevents scurvy) but for various circumstantial reasons the meat hypothesis seemed to be more plausible at the time (1911).

    I don’t think this says anything bad about the scientific process. I think it’s just interesting.

  44. squirrelelite says:

    This one has lain fallow for a while, but I wonder.

    Is this the same Dr David Katz from nuval?

    http://www.nuval.com/

    They have a slideshow today linked to the msn home page:

    http://health.msn.com/nutrition/slideshow.aspx?cp-documentid=100255896&imageindex=1&q=Nutritional+Scores+

    Mostly, it looks like a sales pitch for some nutritional scoring system they have come up with and talked one Missouri school district into using. I give them one point for having a real dietician, not just a nutritionist, helping run the company.

    But, for the examples they cited, I didn’t see any surprise choices you couldn’t have come up with yourself by just remembering:

    fresh is better than fried
    try to eat less fat, sugar, and salt
    get some omega-3 fatty acids when you can
    keep the cholesterol down

    I did notice that one low-scored product was an “organic” food, but I don’t see any big advantage for their scoring system. And, they don’t seem to have an on-line version where you can input numbers for your favorite foods and see how they compare.

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