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Student Health Professionals and Attitudes about CAM

While I’m now two full decades out of pharmacy school, I am occasionally invited to return to give a lecture or facilitate a workshop. Pharmacy education has changed a lot since the 1990′s. For me, pharmacy was a Bachelor’s degree program you started right out of high school. Today, students must have a few years of university completed before they can apply (some already have one degree), and the more common degree granted is doctorate-level, the Pharm.D. The clinical training has been bulked up and the practical training is much more rigorous. I see all this as positive change, as the practice of pharmacy has changed along with the education standard. The era of the “count, pour, lick and stick” pharmacist is disappearing as these tasks are automated or delegated to others. Today’s pharmacist has the opportunity to deliver care in different ways, including new roles like vaccine provider, and medication review/drug therapy optimizer. Many find positions that allow them to leverage their drug-related expertise to other areas of the healthcare system.

With pharmacists’ knowledge of drug products it should not be a surprise that they are consulted widely for advice by patients as well as other health professionals. Public surveys on trust show pharmacists lead other health professionals on this measure. It should also not be a surprise that pharmacists can be quite influential in shaping drug use, particularly when it comes to advice about complementary and alternative medicine (CAM), especially when it is used with conventional, science-based drug treatments. After all, drug stores are becoming (to my professional embarrassment) purveyors of all forms of CAM, ranging from homeopathic “treatments” through aisles of herbal remedies, vitamins, and other supplements. One pharmacy I used to work at sold copper bracelets, magnets, salt lamps, ear candles, homeopathic “first aid” kits, and detox packages that were purported to “balance” your pH. If there was a plausibility limit to what this pharmacy would sell, I never saw it reached. I gave the best science-based advice I could, but eventually left due to my concerns about what was on the shelves. But my time in that setting showed me the opportunity to improve care: the pharmacist is well positioned to advise on the evidence for or against any particular treatment, as well as the describe the potential risks with combining CAM with evidence-based treatment approaches.

Given the continued popular interest in CAM, and its proximity to pharmacy practice, research on roles and professional/ethical responsibilities are of interest to academics and researchers. Regrettably, from what I’ve seen in the literature, those with an academic interest or focus in CAM tend to lean towards being believers, rather than scrutinize the promotion of these products and their incorporation into medical therapeutics. (Pharmacy education really needs its own Edzard Ernst, a fierce critic of CAM, who has discussed CAM and health professional ethics). Almost exclusively the criticism of pharmacy and its role as a purveyor of CAM tends to come from outside the profession, with rare, but notable, exceptions.

Mark Crislip has mused that surveys on CAM seem to be an easy path to getting published, given the thousands that exist. Given my personal and professional interests in CAM and pharmacy practice I couldn’t resist reviewing a new survey of attitudes among student pharmacists. Just published in the Journal of the American Pharmacists Association, and entitled Student pharmacists’ attitudes toward complementary and alternative medicine, the paper is from Marwa Noureldin, a pharmacist and graduate student at Purdue University. The survey included 62 questions and was distributed to first, second, and third-year pharmacy students at 10 schools of pharmacy across the United States. There were 887 complete and usable responses. The average student was 25 years old, white, and female. Among the products categorized as CAM, respondents had personally used vitamins (64%), supplements (48%) and massage (39%) in the past.

The survey was divided into three parts – the first section queried attitudes towards CAM, using Likert scales (1=strongly disagree, 5=strongly agree). Questions were adapted from the CAM Health Belief Questionnaire and were modeled after the National Center for Complementary and Alternative Medicine (NCCAM) categorization of CAM:

  1. Biologically-based therapies (e.g., supplements, vitamins, etc.)
  2. Manipulative and body-based therapies (e.g., massage, chiropractic & acupuncture)
  3. “Mind-Body” interventions (hypnosis, biofeedback, prayer)
  4. “Energy” therapies (e.g., reiki, qi gong)
  5. Alternative medicine systems (e.g., homeopathy, traditional Chinese medicine, Ayurvedic medicine)

Here’s the results (click to embiggen):
Noureldin et al JAPhA Table 2

The CAM Health Belief Questionnaire, while it has been “validated” seems to have been designed by CAM proponents as is evident from the common tropes embedded within the survey. Describing health as a consequence of “balance” that is “self-healing” are subtle references to the ideas of vitalism that are common across many alt-med practices. Notably there is no reference anywhere to the fact that CAM therapies are either not proven effective, or are proven to be ineffective. (Any CAM therapy that is therapeutically effective, is by definition not CAM, and should just be called medicine.). The survey paints CAM as a separate set of therapies that represent an equally valid therapeutic choice, rather than more accurately describing it as a collection of therapies and practices that lack evidence of benefit. The surveys also lumps vitamins in as a category of CAM, when some vitamin use can be appropriate and science-based (e.g., folic acid supplementation in pregnancy). It also include interventions like massage, which, depending on the treatment goal, isn’t necessarily CAM at all.

The student responses lean toward the positive, with most ranging from neutral to strongly agree. This is perhaps not surprising, given how the questions are worded. The strongest support was for the statement “A patient’s health beliefs should be integrated into the patient care process” with 91% of students agreeing. This question is one that could be answered affirmatively by someone that takes a strongly science-based perspective, so what this implies about CAM is unclear. There was also strong agreement that CAM knowledge is required in the practice of pharmacy – a question I also strongly agree with, though my vision for CAM education would likely be quite different than what CAM proponents would like to see. As I have argued before, specialized CAM training in academia is designed and delivered to distract from the fact that CAM (often branded as “integrative medicine”) attempts to embed a double standard of evidence for products and procedures that don’t meet the standard of care for medicine. It should not be surprising then, that students who had taken previous CAM courses had much more favorable views towards the statements in the survey than students without any formal CAM coursework (55.89 vs 48.87, respectively).

The second part of the survey asked about views on acceptability of using CAM with “conventional medical therapies” (the authors’ words), again using the same Likert scale:

table 3 - Noreldin JAPhA

Few students disagreed with any CAM therapy. There was the greatest support for vitamins and minerals (94%, mean 4.29) which could include the science-based use these products. But there was strong support for demonstrably ineffective treatments like acupuncture, with 64% agreeing it was acceptable. Even homeopathy, which any pharmacy student with basic medicinal chemistry skills ought to know is absurd, was supported by over 40% of students. In fairness, these questions could be interpreted in different ways – I agree there are no medical or therapeutic reasons why homeopathy cannot be taken concurrently with actual medicine. However, I’d say the same about qi gong and reiki, yet students gave somewhat less support to concurrent use of those treatments.

Finally, students were asked for the influences on their own philosophy about CAM:

table 4 --Noureldin - JAPhA

The biggest influence was personal experience (“It worked for me”?), which exceeded coursework, faculty attitudes, family and professional experience. Surprisingly there was no explicit question about the direct influence of the scientific evidence itself. Perhaps disappointingly for bloggers like myself, media (including the internet) was cited as the least popular influence, with 25% indicating it was “not at all influential”.

The discussion section of the paper raises more questions about the overall intent of the survey. Negative opinions about CAM (such as concerns about safety and efficacy) seem to be viewed as problems that can be addressed with more CAM education, rather than crucial issues that call into question the entire endeavor of CAM as a distinct system of treatment. Completely absent from the discussion is any statement about the double standard created by specialized CAM education – the authors draw conclusions that seem to suggest that mixed or negative opinions on CAM are problematic, and that more CAM education is advantageous for pharmacy practice.

The limitations to surveys like this are substantial, which needs to be considered as we study the findings. Given this was a voluntary survey, with a low response rate (23%), it’s quite likely that non-responder bias is a factor. It is plausible that those that are indifferent to CAM, or have critical perspectives, may not have participated in the survey. A second factor was the exclusion of fourth (final) year students from the survey. It’s conceivable that students in their final year might have more critical perspectives on CAM. A third limitation is the use of NCCAM’s categorization of CAM which incorporates science-based therapies alongside rank quackery. The result is a mix of science and pseudoscience, bundled up as “CAM”, which could increase positive perceptions, giving unscientific and disproven treatments the appearance of being deemed acceptable. Finally, the statements and questions were worded in ways that fail to distinguish between what’s appropriate from a science-based perspective, and what’s acceptable from a patient-focused perspective. I would never recommend homeopathy to a patient and would actively advise against its use. However, to an insistent patient, I would assure them that concurrent homeopathy use poses no medical consequences. The survey fails to distinguish between the two scenarios.

Conclusion

This survey on CAM attitudes paints a concerning portrait of American pharmacy students. However, limitations in the survey process may have created biases that could have exaggerated the overall perspective presented. More concerning than the results themselves are the researchers’ interpretation of this data: Critical and negative perspectives on CAM seem to be viewed as problematic, rather than positive examples of good critical thinking.

One lesson from surveys like these is they illustrate the educational goals of CAM proponents. Just like “integrative” medicine that is making its ways into academic hospital settings, CAM education on campus is another tactic that is being used by proponents to shape health professional attitudes and perspectives early in their careers. The objective is obvious: normalize pseudoscience with students, and watch it become embedded into pharmacy practice.

Is this going to change? Unless there is a deliberate and explicit attempt to call out and push back against the degradation of academic and scientific standards created by existing forms of CAM education and “integrative medicine” programs, we should expect to see a growing normalizing of pseudoscience in health professions like pharmacy.

Reference

Noureldin M. Student pharmacists’ attitudes toward complementary and alternative medicine, Journal of the American Pharmacists Association, e205. DOI:

Posted in: Herbs & Supplements, Pharmaceuticals, Science and Medicine

Leave a Comment (85) ↓

85 thoughts on “Student Health Professionals and Attitudes about CAM

  1. windriven says:

    Scott-
    Does the paper disclose funding? I ask for two reasons.

    First, it is important to understand who funds this stuff (NCCAM, Bravewell, some other org?). Moreover, if public funds were used for ‘push polling’ I want to raise hell with my Representative. I won’t bother either of my Senators, neither of whom could draw a line from A to B with a straightedge and a bright light when it comes to woo.

    Second, if public funding was involved where does the Journal get off asking for $30 for a peek? This isn’t just JAPhA of course. It pisses me off whenever I have to pay $25 or $30 for information generated using publicly supported funds.

    1. Scott Gavura says:

      @windriven: There is no statement about the funding source. All of the authors stated they had no conflicts of interest to disclose.

  2. agitato says:

    Can pharmacists who work in one of those big chain drugstores actively discourage the use of the CAM products sold there without fear of losing their job?

    1. CHotel says:

      Disclosure: 2013 Graduate, work in hospital currently and for 3 years as a student.

      I believe they could, but it may become awkward when your corporate entity is advertising the products you’re actively refuting, especially when patients come asking about them. When I spent time in a drug store on my senior practicum, they had recently launched one of those “food intolerance” testing kits so I spent several weeks explaining to people why, despite our flyer, they were bullshit. The employees never disagreed, but didn’t follow suit either.

      Avoiding Woo is one of the reasons I stayed in hospital practice.

      1. James says:

        Food intolerances are not Woo.
        For a subset of the population they have real problems with certain foods.
        However how Food intolerances is presented by CAM is Woo.

        I would hate for you to misdiagnose a patient because you do not believe in “Food intolerances”.

        1. WilliamLawrenceUtridge says:

          Food intolerances definitely exist. Scott has discussed them before (here and here). While food intolerances do exist, they are not the same thing as allergies, and as you point out when discussed scientifically are definitely not the same thing as when discussed by CAM promoters.

          1. James says:

            On a side note WUL I started reading the book you recommended “Mistakes Were Made (But Not by Me)”.

          2. WilliamLawrenceUtridge says:

            You’re welcome :)

        2. CHotel says:

          Food intolerances are definitely real. The intolerance tests they offered, that had been developed and evaluated in conjunction with naturopaths and only measured exposural antibodies, were bullshit, hence the quotes. I should have been more clear, my apologies.

    2. Riley Williams II, PharmD says:

      I worked for a chain drug store for several years and actively discouraged patients from buying homeopathic products (unfortunately, stocking them was mandated by corporate, just like selling cigarettes). It was never a problem with my pharmacy manager (who knew that homeopathy was bunk) or the store manager (who left pharmacy to do what pharmacy does). I would love to get into an argument with a store manager or district supervisor who decided he/she could pre-empt my professional judgement over the matter of a $5 box of sugar pills. It would put on a nice show.

      But I’m from Arizona, home of the Naturopathic MD with C-II prescription privileges.

  3. Alia says:

    My mother-in-law is (now retired) pharmacist with MSc title. Fortunately, she never worked in a pharmacy (her last job was with a pharmaceutical wholesaler), because she would fall for every woo there is. Homeopathy, supplements, herbal remedies, energy healing, chiropraxy, you name it. Recently, she’s been considering acupuncture for my father-in-law’s neuralgy – I’m trying to persuade her not to, so far with some success.

  4. Sastra says:

    Finally, the statements and questions were worded in ways that fail to distinguish between what’s appropriate from a science-based perspective, and what’s acceptable from a patient-focused perspective. I would never recommend homeopathy to a patient and would actively advise against its use. However, to an insistent patient, I would assure them that concurrent homeopathy use poses no medical consequences. The survey fails to distinguish between the two scenarios.

    My guess is that the survey fails to distinguish between the two scenarios because many CAM proponents don’t seem to be able to distinguish between the two scenarios. They think doctors ought to recommend anything they think a patient would accept or like. If people enjoy believing in the vitalistic magic and grandiose promises of CAM, then that’s what doctors ought to give them. Who are they to do otherwise?

    From the alt medicine perspective, a “patient-focused perspective” shouldn’t be separated from what’s scientific or reasonable.

    1. WilliamLawrenceUtridge says:

      I would agree with this. If they didn’t think of it, they’re ignorant. If they did, they’re maliciously pseudoscientific, using the cultural capital to sell and market while using its methods as window dressings.

    2. MTDoc says:

      Good point. That’s why I NEVER respond to survey requests, even from sources I respect, because the questions are either stupid, leading, or are agenda driven in such a way as to be offensive to me. I don’t like to be used. So if 76% of the people surveyed didn’t respond, what good is the survey? I actually find this comforting, as they are probably like me.

  5. geekpharm says:

    I’m currently a P2 and my school appears to take a position somewhere between shruggy and EBM. The resource of choice is Natural Standard, which gives homeopathy a “B” rating for acute diarrhea in children, otitis media, postoperative recovery, sinus disorders, and vertigo, to give a feel for how good that resource is. During my community rotations, I have tried to discourage patients from woo, and if someone asks about a certain vitamin/mineral/supplement, I will usually ask if their doctor recommended it and if not to encourage them to get their levels checked before starting it, briefly explaining how most vitamins just pass straight through, especially if you don’t have a documented deficiency. I would love to be involved in a better survey, improving on the shortcomings as illustrated in this post. Maybe I could get a publishing credit. :)

  6. matt says:

    this is the fist time i’ve ever seen someone actually use the word “embiggen” like its a real word lol thats the magic of the simpsons

    1. Scott Gavura says:

      @matt:
      It’s a perfectly cromulent word.

    2. Lagaya1 says:

      On a side note, clicking to “embiggen” doesn’t actually “embiggen” unless you Ctrl scroll, which could be done on the original page. Clicking just gives the same size chart on it’s own page.
      Good article, though.

      1. Scott Gavura says:

        Correction: Click *twice* to embiggen.

  7. Flower says:

    You won’t find evidence if you are not looking for it, or looking in the wrong places. The past decade has seen a lot of research in herbal medicine, nutritional medicine, exercise physiology, mind-body medicine, acupuncture and physical therapies. To claim there is “no valid evidence” is arrogant and wrong.

    An example of a proven natural medicine for depression: The Cochrane Collaboration has found the herb St John’s wort works better than a placebo, and works as well as, and has fewer side effects than drug-based antidepressants.

    A study in the BMJ in 2001 found the herb vitex agnus castus, also known as chasteberry, which is widely used for a variety of female hormonal complaints including premenstrual syndrome, irregular or heavy periods and breast pain, was “an effective and well tolerated treatment” for such symptoms.

    Medical history is also littered with attempts to cure disease that have proven to be worthless or lethal. There are regular reports of drugs removed from the market because adverse effects were concealed before marketing or discovered after they had been inflicted on the public after massive marketing to doctors.

    Of course, if any natural therapies are found to be ineffective or dangerous, they should also be eliminated from the market.

    1. nancy brownlee says:

      @ Flower
      “Of course, if any natural therapies are found to be ineffective or dangerous, they should also be eliminated from the market.”

      How would you suggest that those natural therapies should be evaluated for safety and efficacy?

    2. WilliamLawrenceUtridge says:

      You won’t find evidence if you are not looking for it, or looking in the wrong places. The past decade has seen a lot of research in herbal medicine, nutritional medicine, exercise physiology, mind-body medicine, acupuncture and physical therapies. To claim there is “no valid evidence” is arrogant and wrong.

      Do you know what pharmacognosy is? The problem is your definition of “valid”, as naturopaths and CAM promoters generally think a single study, a case study, a small-N study, an uncontrolled study, an animal study or a petri dish study constitutes “valid evidence” for treatment. Real medicine recognizes that studies can be badly designed, that case studies are indistinguishable from cherry-picking, that animals aren’t people and neither are petri dishes. The real probelm is the misuse of science to justify pre-existing beliefs like “natural is better” (never mind polio is natural, as is a digitalis overdose). Science adopts “natural” remedies that are proven to work in well-controlled studies – so if you want science to recognize “the healing power of nature”, try testing it. And you might also try abandoning the treatment if it consistently fails testing.

      An example of a proven natural medicine for depression: The Cochrane Collaboration has found the herb St John’s wort works better than a placebo, and works as well as, and has fewer side effects than drug-based antidepressants.

      And what are you saying here aside from “science works”? Science also revealed the hitherto-unappreciated possible adverse effects of St. Johns’s wort – photosensitivity, interference with AIDS medications, infertility, induced mania, psychosis, birth defects.

      Also, your summary of the Cochrane review is rather incomplete; you missed the part about how German research tends to consistently oversell it.

      A study in the BMJ in 2001 found the herb vitex agnus castus, also known as chasteberry, which is widely used for a variety of female hormonal complaints including premenstrual syndrome, irregular or heavy periods and breast pain, was “an effective and well tolerated treatment” for such symptoms.

      You mean this study? Yup, science studies herbs for safety and efficacy. Sometimes the herbs are safe and effective, at which point they become part of the mainstream medical treatment options. Did you know chasteberries interferes with the effectiveness of invitro fertilization? What does this show except sometimes herbs have effects? This is already known, it’s why scientists spend lots of time and money evaluating them.

      Medical history is also littered with attempts to cure disease that have proven to be worthless or lethal. There are regular reports of drugs removed from the market because adverse effects were concealed before marketing or discovered after they had been inflicted on the public after massive marketing to doctors.

      Yup, and there are lots of efforts to imrpove this. What’s your point?

      Of course, if any natural therapies are found to be ineffective or dangerous, they should also be eliminated from the market.

      Why should it wait until after they are proven? Why not regulate them like drugs, where they must be proven safe and effective before being sold? Why the double-standard? Would you be in favour of selling drugs that haven’t been proven very effective, but at least have good adverse effects profile?

  8. Leo says:

    I really dislike the methodology of this study. It looks like they purposely lumped silly stuff in with sometimes-good stuff in a way that forces the respondents to seem to be supporting CAM. For example I am an MD and regularly recommend appropriate use of vitamins and supplements (e.g. folic acid for women who could become pregnant, iron for the iron-deficiency anemia patients) and have used massage just because it damn well feels good. I was most shocked that they decided to include PRAYER as a CAM… where I come from, that is called “religion” and not “alternative medicine”, and as someone who was raised Catholic could never deny having prayed myself, but it doesn’t mean I support its use as medicine!

  9. Flower says:

    Re your arrogant comment:
    “It should also not be a surprise that pharmacists can be quite influential in shaping drug use, particularly when it comes to advice about complementary and alternative medicine (CAM), especially when it is used with conventional, science-based drug treatments. After all, drug stores are becoming (to my professional embarrassment) purveyors of all forms of CAM, ranging from homeopathic “treatments” through aisles of herbal remedies, vitamins, and other supplements.”

    I’d like to remind you that “…only 15% of medical interventions are supported by solid scientific evidence…(and)…only 1% of the articles in medical journals are scientifically sound…many treatments have never been assessed at all…”
    (Smith R. Where is the wisdom…? The poverty of medical evidence. Editorial. British Medical J 1991;303(Oct 5):798-799 )

    This suggests that 99% of published trials, or at least the reporting of them – cannot be relied on.

    “…only 5% of published papers reach minimum standards of scientific soundness and clinical relevance” and “in most (medical) journals the figure is less than 1%”.
    (O’Donnell M. Evidenced-based illiteracy: Time to rescue The Literature?. The Lancet 2000;335:489-491).

    “Only 6% of drug advertising material is supported by evidence.”
    (British Medical Journal, February 28, 2004, p. 485 P Rome)

    1. Lytrigian says:

      “…only 15% of medical interventions are supported by solid scientific evidence…(and)…only 1% of the articles in medical journals are scientifically sound…many treatments have never been assessed at all…”

      What you’re missing here is that “medical interventions” cover a hell of a lot more ground than drug prescriptions. Surgeries, for example, are not well-validated in general. It “makes sense” to cut, and that’s why it’s done, but there are a dearth of studies, and this subject has been covered here.

      The reason why most medical — indeed, most scientific papers in general — turn out to be wrong has also been covered here. It’s because the vast majority of papers present small pilot studies, which tend to err on the side of confirming the hypothesis. As studies grow in size and improve in methodology, illusory preliminary results shrink in size and eventually disappear. But negative studies don’t find publishers so easily.

      Fortunately, we do not rely on small pilot studies in science-based medicine. CAM does, but not SBM.

      “Only 6% of drug advertising material is supported by evidence.”

      This is very likely true, but that’s more reason for seeking the advice of a pharmacist, who will be well-informed as to the evidence, not less.

      Even if your figures were terribly meaningful in this context, they’re STILL better than CAM, where the relevant percentages are a solid zero.

    2. weing says:

      “I’d like to remind you that “…only 15% of medical interventions are supported by solid scientific evidence”

      I recall looking into this in the past. I seem to recall that CAM was lumped into the “medical interventions” category.

    3. Sawyer says:

      Oh boy, the infamous 15% statistic. You are not the first person to bring this up here, and it has a number of flaws.

      First off, it should be obvious that this is not the only data point on the effectiveness and scientific basis of modern medicine. There are hundreds of large-scale reviews, meta-analyses, and post-market drug trials that show anywhere from 10 to 90% of treatments are supported by compelling evidence, depending on the field and how successful outcomes are measured. Please spend some time looking for more sources. Do you have enough knowledge of where and how the failures are happening to suggest a path towards improvement? If you can figure out how to narrow your focus and only weed out ineffective treatments go for it, but many critics don’t seem too keen on precision and are happy to throw the baby out with the bathwater. Keep in mind we SHOULDN’T be shooting for 100% – that would imply that no experimental treatments were ever being investigated and medical research would grind to a halt.

      There’s also a huge false premise that’s being implied: if 15% of treatments are supported by strong evidence, then 85% of treatments must be utter failures with no evidence at all, right? Nope, not true. Many interventions do not have the rock-solid evidence that doctors would like. That does not mean they have ZERO evidence. Often the medical literature provides a wealth of information on the biological plausibility of an intervention and a few case-control studies. While everyone would love to have several massive, high-quality, placebo controlled RCTs, do we sit on our hands and deny patients treatments while we wait for those studies to conclude? Let’s say a patient with a life-threatening illness wants a treatment that has a roughly 50% chance of working based on the current available data. Is a doctor supposed to tell them “No, I don’t want to treat you because it might skew the statistics and look me look bad”? Note that we’re not talking about using magical CAM fairy dust here, but medicine that’s based on knowledge of real human anatomy and biochemistry.

      There are numerous shortcomings with the other stats you cited as well, but these topics have been covered multiple times by folks in this community. I don’t think we need to rehash them again.

    4. Carl says:

      Flower,

      The statistic is spun to the extreme, but it is true that there are a lot of bad studies published. That’s why you have to look at the overall collection of available data, and look for the results which tend to come from larger studies done properly.

      What you don’t do is exactly what YOU just did a couple posts up, which is to run around like a dope and grab any one study or statistic which happens to match whatever pet belief you hope to validate regardless of whether or not it conflicts with multiple higher-quality papers..

    5. WilliamLawrenceUtridge says:

      I’d like to remind you that “…only 15% of medical interventions are supported by solid scientific evidence…(and)…only 1% of the articles in medical journals are scientifically sound…many treatments have never been assessed at all…”
      (Smith R. Where is the wisdom…? The poverty of medical evidence. Editorial. British Medical J 1991;303(Oct 5):798-799 )

      Do you base all of your decisions on 20-year-old studies?

      This suggests that 99% of published trials, or at least the reporting of them – cannot be relied on.

      This suggests ignorance of the contents of medical journals, 99% of the articles (not trials) in which would be things other than clinical trials – editorials, meta-analyses, case studies, rat studies, bench research, systematic reviews, erratum and the like.

      Plus, medicine recognizes the fact that not all studies are equal, which is why evaluation of primary source quality is one of the explicit criteria of meta-analyses, and meta-analyses are the most useful tool, the very pinacle of medical research. Do you ever think independently, or just rhyme off whatever you’ve been spoonfed?

      “…only 5% of published papers reach minimum standards of scientific soundness and clinical relevance” and “in most (medical) journals the figure is less than 1%”. (O’Donnell M. Evidenced-based illiteracy: Time to rescue The Literature?. The Lancet 2000;335:489-491).

      You mentioned this study (actually, this set of studies) the last time you were here and apparently have failed to learn from my last reply to it.

      “Only 6% of drug advertising material is supported by evidence.”
      (British Medical Journal, February 28, 2004, p. 485 P Rome)

      Well it’s a damned good thing that treatment decisions are not made solely on the basis of drug advertising and doctors are being informed of this fact as part of their training and continuing education! The pernicious influence of Big Pharma and direct-to-physician and consumer advertising are recognized problems. You could help by lobbying Congress to make at least the latter, possibly the former, illegal.

    6. Xplodyncow says:

      Must . . . resist . . . temptation to clarify . . . I cannot. Ugh. Here goes.

      “Only 6% of drug advertising material is supported by evidence.”
      (British Medical Journal, February 28, 2004, p. 485 P Rome)

      In the US, Big Pharma’s marketing claims are supposed to be based on actual evidence. Fo’ realsies. Otherwise companies risk an FDA smackdown! or worse. In many companies, all advertising — every. single. thing. — is vetted by a team of legal and medical reviewers, and the latter are usually PharmDs. Examples of sufficient “evidence” are a drug’s prescribing information (also called the package insert), a document thoroughly reviewed by FDA scientists, and peer-reviewed articles in high-quality medical journals. Insufficient “evidence” for drug claims includes (for instance) abstracts, post hoc analyses, and data gleaned from animal studies or phase I clinical trials.

      Outside the US, however, it’s more of a free-for-all, depending on the region.

      I wouldn’t be surprised if the statement “Only 6% [...] is supported by evidence” applied to all advertising in general. Supplements, anyone?

      Signed,
      A Big Pharma Shill

  10. After all, drug stores are becoming (to my professional embarrassment) purveyors of all forms of CAM, ranging from homeopathic “treatments” through aisles of herbal remedies, vitamins, and other supplements.”

    LOL :) I have to visit Scott’s Pharmacy, the curiosity is killing me, what exactly does he sell? no vitamins? no supplements? no remedies? The cashflow must be pitiful.

    1. Young CC Prof says:

      And cash is what it’s all about in FBA’s world!

      The ethical drugstore manager will just have to be content with filling legal prescriptions in the back and selling toothbrushes, shampoo and chewing gum up front.

      1. And cash is what it’s all about in FBA’s world!

        We also accept VISA, MasterCard, Discover, Natural Wellness Vouchers, Homeopathy Gift Cards, cashier checks, PayPal, MoneyBookers, American Express and UnionPay attract a small card processing surcharge. Monthly billing options available for regular customers, enquire at reception for details.

        Cash is so 20th century.. still accepted of course.

        1. Carl says:

          Everyone point at the homeopath and laugh.

    2. WilliamLawrenceUtridge says:

      The cashflow must be pitiful

      So…what you’re saying is, it is more important to make money than it is to ensure patients have safe, effective treatments? Yes, I would believe you would say that.

      1. Lytrigian says:

        You see, since “FastBuckArtist” takes his silly notions seriously, he imagines that real pharmacists and MDs really, really are in it for the money alone, and do everything in their power to maximize profit to the detriment of patient health.

        He therefore intended that as a genuine dig, not realizing how it undercut his own thesis.

        1. WilliamLawrenceUtridge says:

          I don’t think so. I think FBA’s name is not a dodge but a true admission – he’s only in it for the money. I don’t think he takes it seriously, I don’t think he believes in homeopathy. Either he lost his faith in the topic, or he never had it. Perhaps he thinks he’s doing a service by providing a sense of control, by providing nonspecific effects that ease suffering in patients. Perhaps it’s just for the money. Either way, he’s a pernicious irritant.

          1. Lytrigian says:

            His avatar is a caricature of an MD; that leads me to think his name is an attempt at an ironic jab at MDs and not really a self-label.

            But even if I’m wrong about that, his perspective seems to be that everyone is really in it for the money alone. Whether he gets that by projecting his self image onto others or from an ill-founded distrust of SBM and EBM does not, perhaps, matter very much.

  11. Flower says:

    The trouble with orthodox medical research is that fraud is very likely second to incompetence in generating erroneous results .

    “Unreliable Research – Trouble at the lab”, The Economist, 19 Oct 2013
    (http://www.economist.com/news/briefing/21588057-scientists-think-science-self-correcting-alarming-degree-it-not-trouble).

    According to the authors of Tarnished God – The Sickness of Evidence-based Medicine, S Hickey & H Roberts, EBM breaks the laws of so many disciplines that it cannot be considered scientific or even rational.

    They also claim that the concept of proof is not scientific, being a feature of mathematics and logic. By definition, logical proof is absolute, however, all scientific knowledge is uncertain!

    According to the authors, the scientific community has unquestioningly accepted the notion of “legal proof” into its paradigm which protects corporate medicine, not patients.

    There’s no such thing as “scientific proof”. A person’s viewpoint can and does skew their results, even when the results are repeatable and the statistical significance is high. For instance, light is both a wave and a particle. You can design an experiment to find “proof” for either, depending on your viewpoint!

    According to Richard Feynman EBM is a “cargo cult”, as it is based on specific ritual methods that supposedly lead to the best evidence.

    These methods are validated by authorities, tradition and organisational approval, rather than by decision science (dealing with the rationality and optimality of choices) and the scientific method. As with all systems based on tradition and ritual, competing paradigms are vilified.

    Medical education is not set up to nurture brilliance. Years of medical training can instil recipients with a stultifying respect for the status quo.

    Further, the RTCs EBM is so proud of are only required to be so large because they study clinically insignificant effects; the larger the number of people enrolled, the greater the effect appears.

    Significance if further rigged by using power calculations, subgroup analysis, multiple outcomes, etc….

    1. weing says:

      “According to Richard Feynman EBM is a “cargo cult”, as it is based on specific ritual methods that supposedly lead to the best evidence.”

      I have not been able to find a reference for this. Could you please provide one?

      “Further, the RTCs EBM is so proud of are only required to be so large because they study clinically insignificant effects; the larger the number of people enrolled, the greater the effect appears.”

      This one too. I’ve never heard of this. I know that the larger the population tested, the more likely you can detect small effects. But that’s not quite the same thing t what you are saying.

      You do realize that this web site is SBM and not EBM?

      1. Flower says:

        Yes, I know – EBM has been supplanted by an even greater cargo cult: SBM.

        The word science was derived from “to know” (Lat. saire). As the philosophy of knowledge (epistemology) states, our knowledge arises from observation and experience. Modern science and, in particular, SBM has substituted the word experiment for experience.

        That is, the results from artificial experiments in an artificial environment and with all other parameters being artificial and contrived – in vitro or on animal models – are deemed to be a more important in terms of evidence than reality!
        Truly absurd – a cargo cult!

        1. weing says:

          “That is, the results from artificial experiments in an artificial environment and with all other parameters being artificial and contrived – in vitro or on animal models – are deemed to be a more important in terms of evidence than reality!
          Truly absurd – a cargo cult!”

          That is not even wrong. I guess some really do prefer illusion and ignorance. How come you are using the results of experiments to communicate your nonsense? The computer and internet are all derived from such artificial experiments in an artificial environment.

        2. WilliamLawrenceUtridge says:

          You don’t know much. The reason this blog exists is because SBM is not mainstream. If SBM were mainstream, the contributors here wouldn’t have to point out, again and again, that homeopathy is nonsense, can’t work, and doesn’t work; herbal drugs would be researched and proven safe and effective before being sold; chiropractors wouldn’t be allowed near infants; naturopathy woudln’t be a profession. The marketing practice of these groups have necessitated such an approach since even doctors, who should know better, are getting suckered in by rhetoric and missing the fact that there’s no evidence to support most of the CAM claims.

          The word science was derived from “to know” (Lat. saire). As the philosophy of knowledge (epistemology) states, our knowledge arises from observation and experience. Modern science and, in particular, SBM has substituted the word experiment for experience.

          And thank Dog, eh? Because personal experience is systematically distorting of reality. There’s a huge body of knowledge in cognitive psychology showing that personal experience bears almost no relation to causality. If personal experience were a reliable guide to treatments and reason, we wouldn’t need science (and homeopathy, naturopathy and acupuncture would have been dropped centuries earlier as ineffective).

          That is, the results from artificial experiments in an artificial environment and with all other parameters being artificial and contrived – in vitro or on animal models – are deemed to be a more important in terms of evidence than reality!

          Which is totally true, since if you can prove something cures cancer in a petri dish and lab rat, you don’t need to conduct human trials. Oh, hold on,you’re lying – that’s why we have phase I, II and III clinical trials and postmarketing surveillance. In vitro and animal models are used to generate and test hypotheses to reduce the risks faced by human subjects. In a way, it probably retards the progress of science – if we could jump direct to human trials we could greatly accelerate the discovery of effective new drugs. It’s just horribly, horribly unethical. You’d have to be a herbalist to do something like that, simply giving people some ground up leaves, bark or roots under the belief that they are safe and effective, with actual evidence to back this up.

          Truly absurd – a cargo cult!

          I don’t think you understand what that means. A “cargo cult” adopts the appearance of something but lacks substance. For instance, homeopathy isn’t scientific, it just pretends to be by having practitioners dress in white coats, publish case studies in journals, and use Latin. Actually, ditto for naturopaths and herbalists. What is missing is the rigor – large studies with control groups, and a practice that changes to reflect the evidence. When was the last time a homeopathic nosode or herb was dropped from practice or a curriculum due to lack of evidence, or evidence of lack of efficacy? You are the cargo cult practitioner, even evidenced by your misuse of, and misunderstanding of the term itself.

          1. Flower says:

            Re your comment: personal experience is systematically distorting of reality, I disagree. Personal experience is the only reality for the individual.

            Moreover, the people who devise, as well as those who conduct experiments are observers, too.

            An observation by Charles Darwin may illustrate the point that all observations are biased (and, therefore, there is no such thing as objective truth).

            “How odd it is that anyone should not see that all observation must be for or against some view if it is to be of service.”

            In other words, you can set up an experiment to “prove” virtually anything.

            People at large are gradually waking up to the reality that we need to ignore higher authorities and find our own way in life to discover what works for us as individuals.

            A typical case in point, and a current debate picked up in the mainstream media is the revelation that the saturated fats and cardiovascular disease link is a myth, propagated for decades by vested business interests.

            As always, enlightened and increasingly independent consumers have been years ahead of the MSM.

          2. weing says:

            “Personal experience is the only reality for the individual.”

            Is it consensual reality? You may be living in a reality of your own that is not shared with the rest of us. But, paraphrasing Crislip, reality don’t care. You can set up experiments to prove anything you want to yourself. You are the easiest person to fool. We learn more by disproving.

          3. WilliamLawrenceUtridge says:

            Re your comment: personal experience is systematically distorting of reality, I disagree. Personal experience is the only reality for the individual.

            For symptoms, perhaps. But if someone feels fine, has absolutely no symptoms, yet has metastatic skin cancer, in an area of their body they are unable to see, are they fine? Symptoms are subjective and important, but if your entire practice is geared towards treating symptoms like pain and nausea, or emotions like fear and comfort, you aren’t improving people’s health, you are providing them with a form of emotion-focussed coping. It’s useless for anything objective, it merely makes you feel better about something you can’t or won’t change.

            In which case, you are the “bucket of ice cream” approach to health care.

            Doctors should provide comfort and symptom relief, as part of actual treatment that is effective and evidence-based. You do not provide the latter.

            Moreover, the people who devise, as well as those who conduct experiments are observers, too.

            Yes, hence the importance of objective measures like death rates, survival curves, genetic tests and the like, as well as the importance of careful record keeping as part of a scientific trial. This is mere handwaving to distract from the fact that there is no science to support your practice (or there is science, conducted by real doctors and researchers, which you are parasitic on, and thus totally redundant to – your profession adds nothing but expense to the delivery of health care).

            In other words, you can set up an experiment to “prove” virtually anything.

            And your solution is to completely give up on scientific testing in order to rely on personal experience instead? It’s funny, because naturopaths and practitioners of herbal “medicine” are quite happy to cite science when it supports their nostroms, and only trot out postmodern bullshit like this when science proves their treatments worthless. For instance, you are perfectly willing to cite the British Medical Journal and Cochrane Collaboration in a previous comment when they supported your viewpoint. Now they’re suddenly worthless? And let’s not forget your willingness to cite 20 year old scientific papers if they supported your point, which adds cherry picking to your crime of postmodernism. You’re a hypocrite then, aren’t you?

            People at large are gradually waking up to the reality that we need to ignore higher authorities and find our own way in life to discover what works for us as individuals.

            Duh, which is why doctors have follow-up visits, and research is ongoing, and personalized medicine with genomic and proteomic testing is a huge area of research. Of course, the average consumer doesn’t know enough about these test and medicine to interpret anything, which is why they must rely on doctors. Eventually you’ll be praising these tests, as soon as you can find an unethical laboratory willing to sell you results that you can in turn use to sell worthless and expensive pills to your patients.

            A typical case in point, and a current debate picked up in the mainstream media is the revelation that the saturated fats and cardiovascular disease link is a myth, propagated for decades by vested business interests.
            As always, enlightened and increasingly independent consumers have been years ahead of the MSM.

            Wrong again. The mainstream media is uninterested in a careful, rational analysis of the debate and discussion. They are perfectly willing, for instance, to interview Andrew Wakefield about vaccines, or Jenny McCarthy, and pretend they are the equal of Paul Offit, merely two sides of an equal story. The mainstream media was willing to talk to a high school science teacher who thought the LHC would create a black hole that destroyed the universe, and to interview them with a straight face. The mainstream media treats climate change deniers as equals to the thousands of real climate scientists, 99% of whom have no doubts about anthropogenic global warming. The mainstream media will happily interview creationists lying for Jesus on the same stage as an evolutionary biologist, and pretend their views have some sort of comparability. Experts know what is going on, the mainstream media is interested in advertising revenue far more than they are in an honest discussion. I don’t treat the mainstream media as a serious source of medical information, and you would be a fool if you did. But then again…

    2. mousethatroared says:

      Flower “According to Richard Feynman EBM is a “cargo cult”, as it is based on specific ritual methods that supposedly lead to the best evidence.”

      The term Evidence Based Medicine started being used in the early 90′s. Richard Feynman died in 1988. I’m having trouble imagining how he could have commented on EBM at all.

      Lately it seems the vogue to use unrelated statements from Feynman to support anything people want them to. It’s like suddenly Feynman is Nostrodumus.

      1. Calli Arcale says:

        Feynman famously coined the term “cargo cult science” in 1974. He was not speaking of science-based medicine or evidence-based medicine, however.

        Putting personal experience ahead of evidence, as Flower has done, and then putting a scientific veneer on that is cargo cult science, because you thus prevent yourself from exploring the possibility that you are mistaken. Flower explicitly rejected the notion that personal experience can mislead, stating that “personal experience is the only reality for the individual.” Given how diametrically opposed this view is to everything contained in Feynman’s original address on the subject of Cargo Cult Science, I can only conclude Flower would not get along well with him, were he still alive.

        Now, it is true that there is a great deal cargo cult science in medicine. Most of what this blog rails against is precisely that, and it is also what enables absolute nonsense such as homeopathy to continue to thrive. But Flower seems to want us to respond with surrender. You can’t prove anything, so just go with personal intuition! That’s so much better! It worked great for the witch doctors, didn’t it?

        “The first principle is that you must not fool yourself–and you are the easiest person to fool.”

        This, of course, comes from the same address as the phrase “Cargo Cult Science”. Flower, I strongly suggest you read the entire address. You will not regret it.

        http://neurotheory.columbia.edu/~ken/cargo_cult.html

    3. WilliamLawrenceUtridge says:

      Further, the RTCs EBM is so proud of are only required to be so large because they study clinically insignificant effects; the larger the number of people enrolled, the greater the effect appears.

      Yes, in many ways scientists and doctors are chasing diminishing returns. The golden age of medicine is past – we’ve identified the major causes of death and eliminated most of them, as reflected in climbing life expectancies for the past century. Most of the causes of death now are lifestyle conditions (heart disease and diabetes) or the consequences of medicine’s success (cancer is more common because people stopped dying of other things).

      If doctors had a magic way to make patients exercise, eat well, quit smoking and get enough sleep, life expectancy would continue to climb.

      We’re no longer forced to deal with the things that shorten life, we’re now facing the inborn characteristics of life itself – degeneration of genes, physical structures, and the gradual accumulation of damage both great and small.

      Fortunately, we’re getting closer and closer to being able to grow new organs in vats; soon we’ll be able to transplant them.

      1. James says:

        After my diagnosis of narcolepsy.
        I realized I had change a lot of the bad habits that I had acquired work around my condition.
        In trying to figure out the best approach to fix my “bad habits”.
        I found that there is only one magic bullet.
        Changing habits is hard and doctors need to realize that these things do take time.
        I would like to see doctors either user a science based approach in helping patients change their habits or send them to someone who does.

    4. Lytrigian says:

      Richard Feynman coined the term “cargo cult science”, but he never applied it to EBM. He used a number of examples in his famous speech, including some from physics, psychology, and other real sciences, but he led off with the example of reflexology.

      He would rather approve of controlled, double-blinded, replicated studies. These are all practices adopted so as to avoid what Feynman was warning against in that very same speech: the tendency of human beings to fool themselves.

      You have the relationship exactly backward. Small effects tend to appear larger in SMALLER studies, not larger. Small or illusory effects will shrink or disappear into statistical insignificance as study size increases.

      1. weing says:

        “Small or illusory effects will shrink or disappear into statistical insignificance as study size increases.”

        Illusory effects, yes. Small effects? Not necessarily. If a drug can shorten an illness by, for example 6 hours. The larger the population studied, the more statistically significant it will become. The clinical significance will remain the same. Statistical significance tells us nothing about the magnitude of an effect.

        1. Lytrigian says:

          I was talking about statistically small effects, not clinically small effects.

  12. Robert says:

    I see acupuncture getting batted around here.

    The 3 times in my life that I had debilitating back pain and extreme stiffness, acupuncture loosened me up enough so I could stretch and rehab.

    I didn’t need a study to prove the difference to me.

    Call me a “believer,” call it the placebo effect.

    I prefer to call myself a pragmatist.

    1. WilliamLawrenceUtridge says:

      See item 5.

  13. Dave says:

    In view of the above statement by Flower that only 1% of articles in medical journals are sound, I thought it might be instructive to list the articles in this month’s American Journal of Medicine. Granted this is only one journal (it just happens to be at the top of the pile on my desk) but it might be interesting to the lay readers who can draw whatever conclusions they wish. There’s certainly not much here to support the idea of journals being only a shill of Big Pharma or being such a terrible source of misinformation:

    4 editorials, one on the discovery that Osler’s nodes and Janeway lesions (physical exam signs of endocarditis) are not due to small vessel vasculitis, two on the use of hand held ultrasound devices for physical diagnosis (here’s the closing quote from one – “we must ask whether this information improves our patient’s health, or instead, whether it merely prompts futher, invasive testing with harms outweighing benefits”. The other editorial is more positive), and one referring to an article on the relationship between hypernatremia and perioperative mortality and morbidity.

    A commentary on the effectiveness (or not) of inferior vena caval filters in treating pulmonary embolism – these seem to be useful in unstable patients but trials are needed for stable patients. As an aside the push lately has been to use this intervention less frequently than we have been.

    A review on the historical development of the medical record from “Papyrus to Electronic tablet”.

    An article on misconceptions and facts about pericardial effusion and tamponade

    An article on bilateral proptosis as a presenting symptom of mantle cell lymphoma

    An article on Chagas cardiomyopathy

    A research article looking at 27 countries and the relationship between gun ownership and firearm related deaths

    The above-referred to article on hypernatremia and postop problems

    An article comparing rate control versus rhythm control strategies in septuagenarians with atrial fib (better outcomes with rate control).

    An article on a program to reduce the number of unnecessary transfusions in a community teaching hospital

    An article on interventions to improve health behaviors and reduce cardiac risk factors in a Middle School

    An article on aortic dissection in black patients

    An article on the psycho-emotional manifestations of chronic valve disease

    There were short reports on a French article about optimizing the use of IV therapy, a Chinese article about cardiovascular risk factor control in type 2 diabetics, and a study from Beth Isreal hospital about the over-ordering of serum ceruloplasmin levels to screen for Wilson’s disease.

    An article on the benefits of hiking in depressed patients

    1. mousethatroared says:

      Clearly big park(a?) is exerting undue influence in the mental health profession. What’s next, gratuitous bird watching for anxiety?

  14. Vicki says:

    It’s not the bird watching that’s useful: it’s the getting away from the computer and television, and getting some healthy outdoor exercise. The birds are, in fact, gratuitous.

    1. mousethatroared says:

      Vicki “It’s not the bird watching that’s useful: it’s the getting away from the computer and television, and getting some healthy outdoor exercise.”

      Well, I suppose, it’s just hard for me to imagine a reason, outside of birdwatching, that one would want to go outside…well, I guess I’m being a bit narrow..gardening and other wildlife watching is nice too. :)

      1. James says:

        This is why I miss working on South Beach plenty of wild life

  15. Self Skeptic says:

    @Dave,

    Do you really think it’s reasonable to defend the reliability of the medical literature, by listing the table of contents of one issue of one journal? (And even if this method were valid, I don’t see how you got from these titles, to your conclusion.)

    I’ve gotten used to the idea that many people think they’ve assimilated a paper by reading the last sentence of the abstract. You’ve offered a novel approach, that may be appreciated as an even better time-saver for the busy clinician.

    1. WilliamLawrenceUtridge says:

      Do you think it’s reasonable to criticize the reliability of the medical literature by quote mining, manufacturing quotes, citing 20+ year old editorials, ignoring the fact that those editorials are efforts by medicine to improve itself, and ignoring why these observations and citations are being made – an effort at a false dilemma?

      Flower/herbalgram11 isn’t interested in an honest discussion of the benefits of medicine. Her comments are a dishonest polemic that try to portray naturopathy as a valid form of medicine. Since naturopathy is nothing but a mish-mash of disconnected, mutually-exclusive, unproven modalities united by dogma and little else, the only way she can do this is by trying to pretend medicine is worthless. It’s a common tactic used by pseudoscientists everywhere. AIDS denialists try to attack the safety and efficacy of AZT as if it would disprove the existence and dangers of HIV. Creationists try to poke holes in the theory of evolution, as if it would prove the Bible to be literal truth. Climate change denialists try to attack world-wide temperature measurements, as if that would make carbon dioxide not a greenhouse gas.

      1. Self Skeptic says:

        @WLU,
        I’m curious; what’s your educational and professional background? Maybe the regulars know already, but there’s no good search function at this site, for that kind of question.

        1. James says:

          I personally believe he is a cyborg with direct link of scientific journals attach to his brain.
          Of course I have no evidence of this.

          1. Self Skeptic says:

            @James,
            Are we talking about the same person? I was asking about WLU. Journal citations aren’t his strong suit.

          2. WilliamLawrenceUtridge says:

            My, what a sneaky way to belittle my contributions.

            It’s mostly a direct linkup to google books actually.

            But seriously. Self skeptic, to answer your question – I have a library card and a long commute.

    2. weing says:

      I thought he was just looking for confirmation of Flower’s claim. He randomly took what was at hand and looked for it there. I still wonder when people make such claims. How are CAM journals categorized? Are they considered an element of the set of medical journals?

  16. Earthman says:

    Embiggen? Is that a word?

    Do have a look at Professor David Nutt who has been pilloried and sacked from government for speaking the truth. He is a hero.

    http://en.wikipedia.org/wiki/David_Nutt

    It is not exactly an issue of pseudo science as it is an issue of government not facing up to science and simple facts. If the facts don’t fit with political policy then the facts are thrown away. Recipe for disaster.

    1. Calli Arcale says:

      Embiggen? Is that a word?

      It is now. ;-) Language does funny things. If someone (e.g. Matt Groening) coins a word, and the world at large finds it useful enough to start using it regularly, it find itself added to the dictionary as an officially real word. A great number of words started out in much the same way.

  17. Dave says:

    Self Skeptic,

    Of course listing the contents of one journal doesn’t prove anything, and I believe I stated it was only one journal. My post wasn’t intended as a scientific review of the medical literature. However, I think some people reading this blog might have never seen any actual medical journals and might have been interested in the contents of one as a taste of what might actually be there, especially after reading Flower’s comment lambasting journal contents. Mark Twain’s comments about the glowing reviews of James Fenimore Cooper’s leatherstocking tales comes to mind.

    Some of the people commenting on this blog seem to think medical journals are full of articles exhorting practitioners to overtest and overtreat with very questionable medications solely to increase profits. There’s actually been quite a bit in the journals recently about the harms of overdiagnosis and overtreatment. I could have used the last edition of American Family Physician, which highlighted what the editors considered landmark studies of 2012. One article questioned treating mild hypertension (systolic blood pressures less than 160) due to the paucity of evidence of affecting mortality or morbidity, another looked at hemoglobin A1C targets and suggested that very tight control might not be wise, and another one gave the statistics which resulted in the US Preventative Task Force recommendations not to use PSA levels as a screening test. There’s actually been quite a bit in the journals recently about the harms of overdiagnosis and overtreatment. I’m talking about the ones I have access to, which include the BMJ, NEJM, American Journal of Medicine, JAMA, the Annals of Internal Medicine and the Lancet. I dont follow the subspecialty journals.

    Flower does have a point, however. I do believe however that published articles are skewed to those with positive results, which is one reason why all positive studies should be replicated by additional confirmatory studies. The current issue of the journal Science (which I also get) has a very sobering article addressing this for those interested. And I think there’s been a major problem with publishing articles pushing drugs because they favorably affect surrogate end points such as AIC levels or lipid levels, rather than clinically important endpoints such as cardiac events. Example – there’s a lot of medications which lower LDL cholesterol or raise HDL levels. There are very few which prevent vascular outcomes.

    Probably the most widely used resource that physicians use for questions about treatment is UpToDate, an on-line resource which exhaustively details the pertinent studies on any topic before giving treatment recommendations. Every doctor I know uses it daily.

    I would recommend that any interested party read Dr Richard Lehman’s weekly journal review, which can be accessed through the BMJ website (www.bmj.com – every week there’s a link to the weekly review). Dr Lehman is a British general practitioner whose avocation is reading most of the major internal medicine journals, including the ones I’ve mentioned, and giving a summary of the clinically relevant articles along with pithy and often humorous comments from the standpoint of a physician who has spent thirty years in the trenches. And yes, he comes down pretty hard on articles touting drugs which improve surrogate endpoints rather than what he calls “patient-important endpoints” and he’s pretty big on pushing for universal access to all studies, negative as well as positive. If you spend a year or two reading his blog you will have a pretty fair idea of what is in the general medical journals. In addition his blog is actually fun to read.

  18. David says:

    We evolved to believe anecdotal evidence as a social species. Cause if some one comes running by screaming about a predator its safer to run than to test if they were telling the truth. But now that we have moved past running from every shadow, listening to someones story about how they were fixed by any of these treatments without skepticism would be foolish.

    But there are still those that want us to dive into the nearest cave when they cry wolf.

    Since this is talking about CAM I figure a link to a great video explaining the utter lack of scientific support for homeopathy would fit. Hope this links properly.

    This is not a bad link to share for all the people here who would like a visual aid to give to the homeopathic curious.

    If you like placebo affects why not just convince yourself that poking yourself in the foot with your finger fixes back pain. Then you can get the same benefits, believe in something unsupported by science, and do it all for free. Personally I have convinced my self that fat turns into muscle if I sit on the couch and eat nachos. Week 10 and I’m super sexy if I divide my weight by my height. I’m just being pragmatic about it. Math is the language of science after all.

  19. David says:

    I messed that up the entirety of the last two paragraphs are the link… sigh.

  20. Tom says:

    They aren’t thrown away. You can attempt to dismiss ideas but if they are supported by science, they will eventually become mainstream knowledge. The problem is that ideas not supported by science hang around forever. People still think that the earth is the physical center of the universe.

    But I am not sure what you are getting at. Sure sometimes people say things the government doesn’t want them to say while they are high ranking individuals. We could also look at M. Joycelyn Elders former surgeon general (1993-1994). Who was fired for giving some healthy advice.

    But i don’t see how this really relates to the pseudo-scientific nonsense CAM believers are trying to sneak into our schools.

  21. Ted Hguygen says:

    This is the worst debunking website I’ve ever seen. You ignore the fact that pharmaceutical drugs KILL over 100,000 people a year! Over the counter pharmacorp drugs kill many as well. This whole BS stance that this website is source of any kind of legitimate information is a joke; your platform is that only science and drug company products have any benefits at all and the rest should not be trusted is ridiculous. Natural medicines have hundreds of years or proven benefits and millions of people are turning away from doctors who literally ask their patients “are you depressed? I’ve got these MAGIC pills that will cure you.” ADDICT you and put money in billionaire’s pockets is what they do, leaving you with horrific side effects and physical damage. This is a debunking website funded like the many fake websites hosted out there to ridicule alternative methods. This website is junk science disguised as truth. I’m sure if one follows the money, who pays the hosting for the website you’ll trace it back to pharmaceutical funded anonymous phony business.

    1. weing says:

      @Ted,
      Do you have any evidence for any of your claims? Or is it just “Everybody knows”?
      Or “It has to be true to agree with my worldview”?

    2. windriven says:

      “This is the worst debunking website I’ve ever seen. You ignore the fact that pharmaceutical drugs KILL over 100,000 people a year!”

      Really? Which debunking sites do you prefer???

      The dangers of prescription drugs have been discussed in these ages many times.

      Please provide citations for:

      Pharmaceutical drugs kill 100,000 per year

      The proven benefits of natural medicines

      And a list of the ‘junk science’ you’ve found in these pages.

      Serve it up Ted. I’m looking forward to dicing it up and having it in my Bun Bo Hue tomorrow.

    3. Chris says:

      Okay. Please read this book review about the discovery of insulin. Then come back and tell us exactly how insulin is killing thousands of people a year with type 1 diabetes.

      Explain to us exactly how those with that kind of diabetes would be better served. Make sure you provide verifiable documentation that a “natural medicine” would make sure kids diagnosed with type 1 diabetes will live a full functional life…. and not die from either starvation or from the act of eating much like what happened early in the twentieth century.

      Thank you.

    4. Sawyer says:

      This complaint has been addressed multiple times on this site. In fact, I’m pretty sure it’s been addressed both AFTER the publication date of this article. Maybe demonstrate some actual curiosity and work ethic and find out how SBM writers feel about this topic before ranting on it?

      And seriously, what’s with all the recent comments from people with internet literacy worse than my grandparents? Can you really not see the word “October” at the top of the page? Would you like to take bets on the 2013 MLB World Series while you’re here?

      1. windriven says:

        “Would you like to take bets on the 2013 MLB World Series while you’re here?”

        :-)

        “what’s with all the recent comments from people with internet literacy worse than my grandparents?”

        Garden variety trolling, Sawyer. These commenters offer nothing to the conversation. They simply want to make an appearance and cast a vote for their “team.” It is idiotic and annoying but it serves as a marker for the general quality of their thinking.

    5. MadisonMD says:

      This is the worst debunking website I’ve ever seen.

      Dammnnn! Could you please send us the links to the GOOD ONES????

      You ignore the fact that pharmaceutical drugs KILL over 100,000 people a year!

      Awww… after that auspicious start, so disappointing that we get was “pharmaceutical drugs KILL over 100,000 people a year! ” Again?

      Yeah– this pharmaceutical crap saves 10s of millions lives per year– pooh. No matter– we need to stop it because it is killing over 100,000! Wait it’s not really 100,000? Hold it, the doctors and scientists were the ones who did the study because they wanted to figure out how to make it medicines safer still? Yep.

      Sorry, this one was debunked *yawn* over 5 years ago by Harriet Hall, by Kimball Atwood and by Peter Lipson

      ———————-

      But Win, this is making me all nostalgic. Remember when….

      We heard this trope just this past October?

      Then there was, of course the ‘rustichealthy’ dude who used it back in Oct ’12. Well, twice.

      How ’bout when Robb did it JAQ style back in September 2012?

      And when good ol’ Stan said it back in Feb 2011? And again in May 2011 (He added + after the 100,000 that time for a bit of style :) )

      Then back in Oct 2009 there was this wales dude who said it.

      Then way back in 2008 someone calling himself ‘beachdoc’ slithered over from Mercola.com way back in 2008 with the cut and paste job– a bit lazy that one.

      Ah the memories. But seriously, Windriven: Any ideas on how we could attract a better class of troll? One with with a critique not debunked dozens of times over 5 years?

      1. windriven says:

        “Any ideas on how we could attract a better class of troll?”

        I wish, Madison. I have come to believe that trolls only exist in a single class. They are the trailer trash of discourse.

        1. Sawyer says:

          There are times when I have considered joining the trolls under the bridge and pretending to be a critic of modern medicine, simply to show them how to have an actual conversation. It’s impossible for them to improve their rhetoric when they don’t have a single example of productive dialogue. If the trolls could see how to build bridges, maybe they wouldn’t spend so much time under them.

          Unfortunately I have neither the patience nor the guile to pull this off.

          1. windriven says:

            And I suspect it would be pearls before swine anyway. Some people are so invested in their beliefs that neither fact nor reason can make a dent. When I lived in the south there was a bumper sticker floating around that held something along the lines of “the bible said it, I believe it, that settles it.” Many trolls are just that doctrinaire.

    6. Chris says:

      Do tell us how well those with type 1 diabetes do with your “natural medicine” instead of insulin?

      (second try, I know I go into automatic moderation, but an entire day?)

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