Articles

The Neurontin Seeding Trial

Any institution that is based upon science is also dependent upon the integrity of the scientific process, and must guard that integrity jealously. That is certainly one of the missions of Science-Based Medicine. A particular challenge is that medicine is a massively expensive enterprise, and growing in both absolute and relative terms. This means that there is a great deal of money at stake (to be potentially earned and spent) and this fact constantly threatens to distort the process of science that is supposed to underlie medicine.

In particular, wherever there are millions or billions of dollars to be made, the motivation to find clever and subtle ways to distort the scientific process is huge. We find such behavior among any industry that has a medical product or service to sell. A recent example of this behavior was recently published in the Archives of Internal Medicine – Study of Neurontin: Titrate to Effect, Profile of Safety (STEPS) Trial.

Krumholz et al. reviewed the documents resulting from Harden Manufacturing vs Pfizer and Franklin vs Warner-Lambert and concluded:

The STEPS trial was a seeding trial, used to promote gabapentin and increase prescribing among investigators, and marketing was extensively involved in its planning and implementation.

Seeding Trials

A seeding trial is a pharmaceutical industry term for a clinical trial whose true and stealthy purpose is not to do science but to expose the investigators to a drug. There  are often many comparable drugs that can be prescribed for the same indication, and manufacturers therefore want their brand to compete with the others. Also, many drugs are underprescribed and raising awareness among physicians and patients about a disease or condition and the availability of treatments will also serve to increase sales. There are perfectly legitimate ways to accomplish these goals — through honest advertising and medical education, for example.

A seeding trial is a dishonest way to promote a drug. The goal of the trial is to make the physicians who are the investigators in the trial more familiar with the company’s drug. This will demonstrably increase their use of the drug. Further, since “clinical leaders” at academic institutions are often chosen to be investigators, the hope is that they will spread their familiarity and use of the drug to their communities (hence the term “seeding” trial).

The authors of the study make note that marketing was involved in the planning and implementation of the STEPS trial. This is a no-no. Pharmaceutical companies have marketing divisions and research divisions, and they must never “cross the streams.” For example, in optimizing a trial as a seeding trial a company may choose many centers, each of which will recruit a few patients (the STEPS trial had 772 investigators). This maximizes the number of investigators, but is probably not optimal for doing good science.

This type of practice is unethical because it violates the trust of the subjects who enter the trial. As a society we have come to recognize that we have a great responsibility to human subjects of research. People offer themselves up to be experimented on with the understanding — the contract — that the research is legitimate, worthwhile, and every attempt is made to ensure that it is safe and that there is a reasonable probability of benefit. People who entered the STEPS trial did so with the understanding that the study would help improve the practice of medicine, while the real purpose was to promote a product.

The Archives paper gives ample evidence that the STEPS trial was not good science. It was uncontrolled and unblinded, with vague outcome measures. These concerns were even raised prior to implementing the trial. In short — it was bad science, probably because it was designed by marketers.

Conclusion

We can add seeding trials to the list of deceptive practices by industry that distort the science of medicine. This practice was known about prior to the Archives paper — but this is perhaps the best documented instance. I have also written before about companies ghostwriting scientific papers as another example of a deceptive marketing tool. These practices erode the institution of medicine. It seems that eternal vigilance is not only the price of freedom, but scientific integrity as well.

Posted in: Pharmaceuticals

Leave a Comment (35) ↓

35 thoughts on “The Neurontin Seeding Trial

  1. windriven says:

    “Also, many drugs are underprescribed and raising awareness among physicians and patients about a disease or condition and the availability of treatments will also serve to increase sales.”

    By what measure are “many drugs … underprescribed?” Do you refer here to so-called orphan drugs for rare conditions or to specific drugs in the constellation intended to treat more common diseases. Drug companies are not known for their reticence in marketing their products. How can broad underprescribing be reconciled with the perception that drug companies overmarket their products?

  2. WilliamLawrenceUtridge says:

    Was it registered in the US clinical trials database?

    I’ve wondered if there was a potential for grant reviewing agencies to include methodological rigor in applications and administration of post-award funding.

    But the real guts of my question is – what control could be exerted over a company-funded “trial”?

    Really, the only ways I could see would be:

    1) To involve the institutions themselves (either hospitals or universities) in screening the actual trials and science conducted. However, given these institutions are basically whoring themselves out for Pepsidollars to pay for their gym floors, they’re probably unlikely to turn down extra funding.

    2) Train doctors to better understand the scientific process and the involvement of drug companies, in particular to get them to turn down scientific “opportunities” that involve shoddy and useless science.

    There’s no perfect system I guess…

  3. cervantes says:

    I don’t think that underprescribing is nearly as big of a problem as overprescribing — particularly when it comes to psych meds, which in the majority of cases do more harm than good.

    I’m glad to see SBM taking on criticisms of the biomedical research enterprise. I’ve often commented here that woomeisters wouldn’t get nearly as far if they didn’t have so much truth to work with when it comes to the deficiencies of medical practice and the medical-pharmaceutical complex. Unless medicine really walks the walk when it comes to science we’re always going to be vulnerable to people who tout “alternatives.”

  4. GLaDOS says:

    I don’t think that underprescribing is nearly as big of a problem as overprescribing — particularly when it comes to psych meds, which in the majority of cases do more harm than good.

    Wow, thanks for the heads up about psych meds.

    Most doctors wouldn’t want to cause their patients more harm than good, so you really have to wonder about the ones that choose to specialize in psychiatry. Do you think they’re the dumber students in their med school class, or just a little more evil than the rest?

  5. Calli Arcale says:

    Overprescribing and underprescribing are both real phenomena, but they’re context dependent.

    There are drugs that would work well for a particular indication, but not many doctors know about it. That would be underprescribed from a medical sense. And of course there’s the marketing sense; any drug that they’re not selling enough of is underprescribed. So one might attempt to fix “underprescribing” with either noble or selfish intentions. (Sometimes both.)

    There are psychiatric drugs which are underprescribed, I have no doubt. Some of this is because of ignorance. Some of this is because of effective marketing by the purveyors of competing therapies. The former is probably easier to fix. For instance, there is an increasing trend of prescribing antidepressants to children with attention deficit disorder, offlabel, instead of the venerable stimulant medications that are not only *on* label for children with ADD, they are actually studied in them and are available at appropriate doses.

    I actually think stimulant medications are likely both overprescribed *and* underprescribed — that is to say, not all patients who should be getting them are, and there are patients getting them who shouldn’t, for a variety of reasons.

    I could totally see a drug company trying to pull this sort of crap to increase sales of, for instance, an antidepressant med. To a sales person, this would be opening a new market.

  6. Frank says:

    “2) Train doctors to better understand the scientific process and the involvement of drug companies, in particular to get them to turn down scientific “opportunities” that involve shoddy and useless science.”

    Besides a few side-comments by some professors during med-school there was no education at all how to deal with these kind of things in my faculty. Did you had different experiences?

    A bit off-topic: a small but clever marketing strategy I encounter nowadays is the free supply of some branded drugs to my hospital which in turn the apothecary insists on me prescribing them instead of the cheap generic ones during hospital admission. The result being – unless you’re aware of it – you send people home with Nexium (aprox 30 euro/month) instead of eg. generic omeprazol (1,50euro/month). Not a real health risk here, but not very desirable either.

  7. tmac57 says:

    I’d like to see a new category added to this site for articles like this. Call it:
    ‘Why We At SBM Are NOT Big Pharma Shills’

    Too wordy,I know,but you get the idea.

  8. windriven says:

    “I could totally see a drug company trying to pull this sort of crap to increase sales of, for instance, an antidepressant med. To a sales person, this would be opening a new market.”

    When is it ‘crap’ and when is it medically useful? Viagra was originally, I think, released to treat angina. Erectile dysfunction was initially an off-label indication.

    It is a drug company’s responsibility to inform physicians about its products. It is the physician’s responsibility to judge that product in comparison to other treatments available for a specific patient’s needs.

  9. cervantes says:

    GLADOS — I recommend you read Anatomy of an Epidemic, by Robert Whitaker.

  10. GLaDOS says:

    Whitaker can kiss my ass.

  11. cervantes says:

    I should have given a link — sorry.

    It’s here.

    “About the Book
    Anatomy of an Epidemic investigates a medical mystery: Why has the number of adults and children disabled by mental illness skyrocketed over the past fifty years? There are now more than four million people in the United States who receive a government disability check because of a mental illness, and the number continues to soar. Every day, 850 adults and 250 children with a mental illness are added to the government disability rolls. What is going on?”

    The first chapter and all references are available free on line. BTW, Whitaker’s is far from the only book to make this case recently. Marcia Angell reviewed three of them in NYRB last month. Also see “Manufacturing Depression” by Gary Greenberg.

  12. CarolM says:

    “Do you think they’re the dumber students in their med school class, or just a little more evil than the rest?”

    Talk therapy is a drag…prescribing pills is easier. A friend has to go to a shrink every couple months to keep her lithium going, which in turns keeps her disability check coming in. She usually just shows him cartoons cut out of the New Yorker, they chuckle a bit and all is good.

  13. Harriet Hall says:

    I have two posts scheduled for later this month that will address drug companies’ failure to publish negative trials of antidepressants, the “epidemic” of mental illness, and various other issues raised in Marcia Angell’s NYRB article about psychiatry and psychotropic drugs. Check back on July 19 and 26.

  14. CarolM says:

    Haha, good. I was just about to post the link. Really look forward to it.

  15. SBM’s opposition to CAM is all about defending big pharma and your prescription profit farm. Why do you guys always pick on CAM and never on your big pharma cash cow? /end sarcasm

  16. WilliamLawrenceUtridge says:

    Frank:

    I’ve no experience in med school – I just read on the topic, here, on other blogs and the occassional book. I believe the lack of critical analysis of research in med schools has been brought up by Drs. Gorski and Novella (at least) in the past though I don’t know if there’s a whole post on it. The comment tailors neatly with the discussion of acupuncture in particular, where a “positive” study is only “positive” in the loosest sense – it doesn’t support qi, meridians, acupuncture points, needling or traditional chinese medicine, but it does support lengthy consultations, an exotic explanation of the problem and a dramatic intervention. All things that enhance the placebo effect. Bad Science by Ben Goldacre is a good book for this sort of analysis.

    GLADOS and others – psychiatrists would love to have tests that reliably distinguishes between “organic” versus psychogenic mental illness, effective interventions that treat both, and enough time to do a good job with either approach. Psychiatry is an unusually difficult branch of medicine as it lacks much of the objectivity that underwrites other branches and is generously slathered with the societal preconceptions and biases about mental illness. Psychiatrists aren’t evil, but they do a hard job, on the most complicated thing we are aware of (that actively lies to itself!), with generally little respect, questionable results and a lot of criticism in a society that is rapidly changing in its expectations for children, adults, parenting and education. It was much easier in the past where everyone had strict roles, your peers were the people around you rather than the people you saw in advertising and television and you could institutionalize the problematic. Now everyone expects happiness, success, gratification and solutions. Science is a victim of its own success and instant, reliable cures are expected for nigh-everything, even as science (and scholarship in general) itself is exposing and cutting away at many of the foundations of society itself. We’re still apes, living far from the forest.

    Anyway, there are good psychiatrists and bad; there are effective drugs and ineffective ones; there are patients who respond and those who don’t; there are those who abuse their power and those who don’t. There is no such thing as an “all X is Y” unless it’s an axiomatic definition.

    (dismounts from soapbox, looks embarassed)

  17. Indeedy, this a nice post to cite in the future when responding to the Pharma Shill Gambit, and to make the more general point that SBM contributors criticize bad science no matter where it comes from. I’m thinking of starting a list of such posts.

    Ha, “cross the streams”! Good geek reference. 26 seconds of nostalgia on YouTube.

  18. To involve the institutions themselves (either hospitals or universities) in screening the actual trials and science conducted.

    This is already done, and has been for many years, in the form of the Institutional Review Board (IRB). I’m a member at my hospital, and in the past 2-3 years we’ve ding’d more than one application for what was rather obviously a “seeding” trial (in these cases the trials were to be of devices, not drugs). Nevertheless, many, perhaps most IRBs are not up to the task of identifying each of the many ways in which trials can deviate, in subtle or even blatant ways, from protecting human subjects. Witness examples provided here on SBM: Gonzalez, chelation, homeopathy in children.

  19. vicki says:

    I suspect that there are a number of reasons why more people are officially disabled with psychiatric diagnoses in the past. For starters, how much of that is an increase as a percentage of the population, and how much is that there are twice as many Americans as fifty years ago?

    There may be some actual increases in disability: for example, some Iraq and Afghanistan war veterans are coming home with PTSD and significant physical injuries, where someone with the same level of injury fifty years ago would have died.

    Beyond that, whether a person has a disabling condition, and whether it’s recognized and they get a disability check, are very different things. Without that, people might be simply abandoned, or their care might be entirely at the expense of relatives (mostly female) who are expected to do it out of love or a sense of duty.

    It’s easy to say “more people are being diagnosed with these problems than in the past,” but that leaves (very broadly) three possibilities: (1) an increase in the real incidence, (2) that the condition is now overdiagnosed, or (3) it was underdiagnosed in the past. Or some combination of an increase in the real incidence and a change in how likely something is to be diagnosed. Doctors may be more likely to give a specific diagnosis if they have a way of treating it: that isn’t evidence of over-diagnosis now rather than under-diagnosis in the past.

  20. Nate Dogg says:

    GLaDOS is being sarcastic, those of you who are impaired.

  21. Nate Dogg says:

    @WilliamLawrenceUtridge

    “1) To involve the institutions themselves (either hospitals or universities) in screening the actual trials and science conducted. However, given these institutions are basically whoring themselves out for Pepsidollars to pay for their gym floors, they’re probably unlikely to turn down extra funding.”

    A study has to pass IRB review at every single center involved in the study.

    The IRB reviewers are not taking the gym floors into account (well, hopefully).

  22. Nate Dogg says:

    “Pharmaceutical companies have marketing divisions and research divisions, and they must never “cross the streams.””

    This varies by company, but generally speaking when a pharmaceutical treatment has an approved NDA, it leaves Research and falls under the purview of a group called Medical Affairs.

    Medical Affairs is basically a fuzzy amalgam of research and marketing. They may do science/medical stuff like conduct pharmacovigilance and design and monitor Phase 4 studies, and legitimate industry outreach like sending out MSLs and putting together advisory boards, but they’re also very much involved in helping Marketing figure out ways to push the drug.

  23. Nate Dogg says:

    That said, the kinds of antics that pharma could get away with in the ’90s (when STEPS was conducted) are not a good barometer of industry practices today.

  24. Diomedes says:

    “Talk therapy is a drag…prescribing pills is easier. A friend has to go to a shrink every couple months to keep her lithium going, which in turns keeps her disability check coming in. She usually just shows him cartoons cut out of the New Yorker, they chuckle a bit and all is good.”

    What’s your point? Would you prefer that she not be on lithium, and go in for behavioral therapy? Where’s your evidence that this would be superior?

    Lithium is the gold standard of treatment for bipolar patients and is also occasionally used for chronically depressed patients that are a severe risk of suicide. In fact, it is the only psychotropic drug that has been clinically demonstrated to significantly reduce the risk of suicide in bipolar patients (Baldessarini et al. 2006, Bipolar Disorders 8:625-639) (someone correct me if I am wrong). It is typically prescribed to patients who are considered a significant suicide risk, and is not prescribed lightly either, because of its occasional tendency to cause kidney damage and the elevated risk of fetal defects it poses for female patients who are of childbearing age.

    Many patients see a psychiatrist for a 15 minute appointment every few months for a med adjustment, and have a separate appt with a behavioral therapist, who frequently coordinates meds with the psychiatrist. Patients that are on long-term lithium therapy might get behavioral therapy at the beginning of their treatment, but they don’t necessarily need it continuously.

    Do you have a better idea for bipolar patients who are at a several risk of suicide? Where’s your evidence that talk therapy would be more effective for your “friend”?

    Really interesting article on gabapentin. I’ve watched this drug slowly fall out of favor for treating bipolar patients. I’d be interested to see what evidence there ever was for its use.

  25. Diomedes says:

    Pardon: at a *severe* risk of suicide

  26. qetzal says:

    WilliamLawrenceUtridge asked:

    Was it registered in the US clinical trials database?

    I couldn’t find it at ClinicalTrials.gov, but from what I can see, that database didn’t debut until 2000, and I don’t think FDA started requiring trial registration until some time after that.

    The STEPS trial was apparently performed in the mid to late 90s. There are cetainly other trials from the same period that are in the database, but it was entirely voluntary back then.

  27. Lytrigian says:

    I’m afraid my own experience with the specialty has made me rather cynical of psychiatry.

    I was uncomfortable with it to start with, as I never got much of a sense they knew what they were doing. When my own depression became severe enough to cause me to seek therapy I first went for talk therapy, and after a formal diagnosis from him saw a psychiatrist he recommended.

    It was a process of experimentation with the psychiatrist. He tried several different drugs in various combinations — Bupropion, Effexor, and Buspar — and the only criteria was how I subjectively felt I was doing from one month to the next. I was never NOT depressed while under his care, and mostly suffered from some unpleasant side effects. (GI stuff, including the worst gas I’d ever had in my life, dry mouth, and “brain zaps”.) That my mood might naturally vary was never considered, nor was the notion that any apparent improvement might equally be due to the talk therapy.

    Due to a chronic inability to focus at work, he also diagnosed me with ADHD and prescribed Adderall.

    Whatever combination he prescribed seemed to work for a while, but never for very long. When I asked what I thought was a reasonable question — How can I tell this stuff is working? — there were various answers:

    – It should make me feel “normal”, an answer echoed by others I talked to who felt antidepressants had helped them. Well, here I was a gay man in a very unhappy hetero marriage to a clinically depressed woman and with two special needs children (one severely disabled with cerebral palsy, the other autistic) and in a career that held no real interest for me. Maybe depression *is* normal in that situation. (It had been a very long time since I felt really happy.) When I brought that up, I was given nonanswers. Or,

    – That’s not a valid question. It seems that you can’t judge psychiatric drugs that way. That answer struck me as not very reasonable — the side effects were certainly clear enough, so why not the clinical effects? — and I said so. This annoyed him. When I described his reaction to my talk therapist he summarized the response I got as “shut up and take the pills”, which I felt was fair enough at the time.

    The Adderall didn’t seem to be doing anything either. When I suggested that maybe I was just lazy, that this wasn’t so much ADHD as a character flaw, he actually burst out laughing.

    In the end I simply stopped seeing him and tapered myself off the drugs. The side effects disappeared, with the possible exception of the breaking of a few old habits (including good ones such as exercise) and the crumbling of long-established belief systems. Whether that came from the Bupropion I have no idea, but seeing as that’s what it’s also used for I don’t feel I can discount it. (He didn’t mention it was also used for smoking cessation.)

    The talk therapy has done me much more good.

  28. Anthro says:

    “particularly when it comes to psych meds, which in the majority of cases do more harm than good.”

    Such a sweeping generalization. Evidence?

    One book? An “explosion”? Isn’t that what they say about autism over at Age of Autism, et al? Maybe the stigma is lessening and more people are seeking help? Maybe research has improved diagnoses? Maybe personal anecdotes don’t equal data?

    This whole discussion (of psych conditions and meds made me think I was on an anti-vax or Scientology blog.

    I look forward to Dr. Hall’s upcoming post.

  29. WilliamLawrenceUtridge says:

    Oops, if I missed sarcasm from GLaDOS, my apologies. I often read too quickly and I wouldn’t be surprised if I misinterpreted something obvious.

    Re:IRBs, I thought they looked at ethical issues; the only way I could see a study being quashed for ethical reasons in this case would be the fact that the study’s methods were too shoddy to meaningfully answer a research question. Is there such a thing as an ‘ethical methodology’?

    I always find it fascinating to get a glimpse of the innards of the day-to-day realities of research from people who are in the trenches. Had I my druthers, researchers would enter labs and lecture halls like Hulk Hogan entering an arena during Wrestlemania.

    I think we can all agree it’s a good thing my druthers are kept from me.

  30. CV “I don’t think that underprescribing is nearly as big of a problem as overprescribing — particularly when it comes to psych meds, which in the majority of cases do more harm than good.”

    Whenever I read this sort of comment, I think, ‘ sounds like someone who’s never had to run from the house to call the police because their sibling with schizophrenia has decided they are over medicated, stopped taking medication, then gotten so paranoid that they pull the handrail off the steps and start swinging it at anyone in the house. Or maybe someone who has never received a call that their bipolar loved one has overdosed on alcohol and oxycontin during a manic episode, once again.’

    Then I think, ‘well lucky them, must be nice to have the kind of life where you can believe the world mostly contains kids who’s parents spoiled them and give them Ritalin to behave and slackers who just are faking it to get a government check.

  31. Tell it like it is says:

    OLD MOORE SHOUTS ME ME ME

    My strap-line is referring to G E Moore the English philosopher, and not ‘Old Moore’s Almanac’. The relationship will become apparent in a mo.

    Before I add my two-penneth, may I say without fear of condescension that this is one of the best thought-provoking articles I have thus far found on this site. If it were possible to give articles posted here a ‘star’ rating I would give it FIVE!

    Moore is best known for describing ‘naturalistic fallacy’, by which he meant that natural properties cannot imply moral goodness.

    If you have dipped your toe into Moore’s ‘Principia Ethica’ you will know that towards the end, Moore makes the very subtle distinction between the value that a thing possesses ‘on the whole’, and the value that a thing possess ‘as a whole’.

    The value of a thing ‘on the whole’ refers to its ‘overall’ value, whereas, the value of a thing ‘as a whole’ refers to the value that is ‘added’ – its ‘contribution’ that goes far above the value of the parts that make up the whole. Moore sums this up with the idiom ‘The sum of the parts is greater than the whole’ (think bicycle – think Viagra).

    In ‘Old Moore’s Almanac’ we are confronted with an abundance of prophesies – things that can only come true if the conditions are present for them to do so.

    In neurontin seeding trials are we confronted with Moore? – or Moore?

    Regards,

    TILIS

  32. Re: IRBs, I thought they looked at ethical issues; the only way I could see a study being quashed for ethical reasons in this case would be the fact that the study’s methods were too shoddy to meaningfully answer a research question. Is there such a thing as an ‘ethical methodology’?

    Yes and no and yes and yes. A huge topic, of course, can’t do it justice here, but: the first priority of an IRB is to “protect human subjects.” The meaning of that has evolved from obvious physical risks to a more general, ethical construct, which includes methodology. According to Emanuel et al (a useful primer),

    To be ethical, valuable research must be conducted in a methodologically rigorous manner.​ Even research asking socially valuable questions can be designed or conducted poorly and produce scientifically unreliable or invalid results. As the CIOMS guidelines succinctly state: “Scientifically unsound research on human subjects is ipso facto unethical in that it may expose subjects to risks or inconvenience to no purpose.”

    The seeding trial discussed here is also almost certainly unethical in that it probably did not disclose its real purpose to the subjects. Conflicts of interest (of investigators, sponsors, manufacturers, and any other interested entities) must be stated in order for consent to be informed.

    That said, most US IRBs consider boilerplate language such as the relevant US codes (here and here) rather than formal ethics statements per se, even though the US Office of Human Research Protections cites the Belmont Report, and nearly all medical journals require authors to assure that they’ve been true to the Helsinki Declaration. Much in those codes overlaps with Helsinki, for example, but not all.

  33. cervantes says:

    Anthro — It’s not just one book, it’s a veritable movement. Marcia Angell is doing a series on it in NYRB, which Dr. Hall has promised to discuss. And I can tell you, as a regular reader of BMJ, that there is a great deal more skepticism in Europe about psych meds than there is in the U.S. British physicians no longer prescribe antidepressants as a first resort in depression, and good for them.

  34. CarolM says:

    “What’s your point? Would you prefer that she not be on lithium, and go in for behavioral therapy? Where’s your evidence that this would be superior? ”

    True, my friend was a bad case, and was suicidal at one point. Her actual therapy unfortunately occurred during the “recovered memory” hysteria, so she “learned” that she’d been molested by her father (she since recanted). I mean, wasn’t everybody?

    She’s actually on a substitute drug now because even the psych didn’t seem to detect that her balances were out of control and she became housebound and dehydrated. This came to light after I’d rousted her out of her apt and taken her to ER.

    But my cynicism is more justly based on other experiences, recent and long past.

  35. elmer the fake nutritionist emailer not says:

    Of course the Neurontin scandal has been quite well-publicized for a few years now, but for those who missed it, the context was that this was just part of a large web of techniques to aggressively, and very successfully market it for off-label uses for which there was zero evidence, when even the evidence for on-label use not particularly strong, and the only reason this came to light was that a single employee in the company had the courage to blow the whistle despite the company’s threats to destroy him if he did so. Marcia Angell seems to have the impression that seeding of this sort is pretty common.

    I’ll just note that, despite the very, very, occasional appearance of posts like this from Dr. Novella, there seems to be a fairly consistent pattern as far as what he considers important or not, and what he considers generalizable or not.

Comments are closed.