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Two Viewpoints

Most of what I read professionally is directed towards reality-based medicine. I spend my professional energies thinking about the application of reality to killing various and sundry microscopic pathogens.

The conceptual framework I use, and that used by others in medicine, does not concern itself with the application of the Supplements, Complementary and Alternative Medicines that occupy the attention of this blog. In acute care medicine SCAMs are of virtually no importance yet the approaches we need to take with patients and medicine are, with slight changes in emphasis, as applicable to SCAMs as real medicine. You need to remember, however, that the topic is not necessarily based in known reality.

Two viewpoints in JAMA caught my attention this month, both more thoughtful and reasoned than I am probably capable of. While focused on the application of reality-based medical practice, they apply to the topics of SBM as well.

The first is Evidence-based persuasion: an ethical imperative.

Evidence-based persuasion.  At some level the raison d’être of this blog and the antithesis of the SCAM world. That it is considered an ethical imperative makes its lack of use in the SCAM world all the more damning.

The article points out in the introduction that:

There are at least 3 different types of persuasion. The first is the removal of bias. The second is recommending a particular course of action and providing evidence and reasons in favor of it; and the third is the potential creation of new bias, which could cross the line into unethical manipulation.

They go on to give examples applied to the practice of medicine. How about science-based medicine?

The first kind of persuasion, the removal bias, is the primary theme of this blog. Readers and writers of this blog are aware of all the types of bias that can warp judgment. I have long said that the three most dangerous words in medicine are “in my experience” because experience is unreliable in helping decide what works.  Experience in medicine is the worst bias.

Ignoring experience is an unnatural way for humans to behave. Everything we do is a result of experience. The best restaurant in town*? The fastest way to work? Best headphones? In every aspect of life we rely on our experience and that of our social network to decide what to do. And then we get to medicine, the attempt to heal illness and relieve suffering, and we are asked to lay aside a lifetime’s approach to the world and rely on clinical trials? Not likely.

I had a patient just a few weeks ago ask me if she could take colloidal silver for her infection and I told her it does nothing. She countered that I was wrong, that she had used it many times in the past and it had always cured what ailed her. I knew I had not a chance in hell if convincing her otherwise for as Groucho said, who are you going be believe, me or your lying eyes?

Perhaps people are able to alter their biases when presented with the evidence, but I am not sure everyone is capable. When someone suggests that the reason I recommend vaccines, or any other reality-based therapy, is because I am a paid shill of big Pharma, I know that we inhabit two radically different realities that do not overlap. Such sentiments are not uncommon:

…one in seven Americans think the pharmaceutical industry is colluding to “invent” new diseases in order to profit off them…

Weird. Sure Big Pharma, like all companies, can behave with all the ethics of a psychotic shark, but the conspiratorial nature of some biases is just nuts.

In medicine when we discuss diagnostic and therapeutic interventions we sometimes have to dissuade people of erroneous ideas that could prevent them from accepting care. It is rare in my world. Most people, when acutely infected, accept the interventions I have to offer since the alternatives are rather unpleasant. The only common interaction is the occasional new AIDS patient who refuses HAART because they are convinced the medications are toxic and kill people. After explaining the history of HIV treatment I usually convince them to give it a try. As a result I have many patients who would have died in months in the bad old days who are now alive a decade later. Very satisfying.

But what if your whole practice is based on bias, on unreality, and you cannot realize it? The only bias you can alter is to convince your patients that real medicine is fantasy and that fantasy is reality. Welcome to Natural News, the bizarro world of medicine.

How about the second? “Recommending a particular course of action and providing evidence and reasons in favor of it.”  Hard for a SCAM provider.

In my practice, hospital-based acute infectious diseases, it is reasonably simple. I know most of the pertinent literature for the common infections and if I have some weird bug in an odd place I research the problem and tell the patient the whys and wherefores of the proposed treatment. I know the science, I know literature (not always the same thing) and I know the best options.

What about a homeopath or acupuncturist or reiki practitioner? Can an Integrative Medicine Department ethically offer using these therapies after comparing them to the known world?

It is an interesting psychology: based on nonsense that is a polar opposite to the understanding of reality, the only favorable evidence that can be offered is “in my experience.’ It is a curiosity that real medicine uses what can be the least convincing arguments, those from the literature, while the homeopath has to rely of the least valid but most powerful argument, experience.

My patients often want to know what kind of experience I have. Has this worked before, how many of similar cases have I managed, and what would I suggest if it were my mother? I am always slightly unnerved with the question because I know how faulty my memory is, especially after almost 30 years of medicine. That’s maybe 25,000 cases. Like I can remember? But that is all the average SCAM provider has to offer.

The last form of persuasion, that of creating new biases, is the most interesting. It is an interesting balance. Patient autonomy is paramount in US medicine. They are the captain of their ship and it is my job to give them my best opinion as to their diagnosis and treatment. On the other hand, the process of explanation will persuade them and we all know the context of how information is given can create bias.

However all SCAM is about creating new biases that are divorced from reality.

It would interesting to get an ethics consult and ask the question of a hospital’s integrative medicine department if they can live up to the recommendations of ethical persuasion:

1) Remove bias and access the patient’s autonomous wishes
2) Provide honest, impartial, evidence-based information about prospective harms and benefits
3) Provide a rational interpretation of this information including facts about the belief set and views regarding the best decision
4) Use reason rather than emotion while sometimes appealing to the patient’s emotions to counterbalance their existing emotional responses
5) Avoid creating new biases
6) Be sensitive to the patient’s changing preferences because persuasion is likely to change the patient’s outlook and perspectives.

The heart of all SCAM is in violation of the first 5. Given they are not based on known reality, they cannot follow those recommendations and it should be unethical to offered in a real medical environments.

However, SCAMs make money, and where money is concerned, rationalizations will follow.

The other viewpoint that caught my eye in JAMA was Synthesizing evidence: shifting the focus from individual studies to the body of evidence.

The first sentence is intriguing:

The research enterprise behaves as if a single study could provide the ultimate answer to a clinical question.

The rest of the essay is an argument that more emphasis should be placed on the results of meta-analyses and not rely on single studies.

I do and do not agree with the authors, but there are always caveats.

One of the issues that has always annoyed me with meta-analyses is that often as new studies are done they are incorporated into the prior analysis but the older, often more poorly done studies are not thrown out, so the bad studies tend to pull down the good ones.

The Cochran Collaboration has a nice overview of the systamatic review process but they are done under the implicit assumption that what they are reviewing are studies that evaluate reality. The Cochrane Reviews usually fail when they apply their methods to topics such as homeopathy or acupuncture, where positive results are always due to bias.

Even though they assess the quality of the studies, they do not take into consideration the prior plausibility that renders most SCAM studies suspect.

There is an arc in the literature concerning most SCAMs. Better and better quality studies demonstrate less and less efficacy until well designed studies demonstrate no effect.

The potential for that arc, as best as I can tell, is not part of the systematic review, but would give a hint as to the validity of studies where the intervention is divorced from reality. A plot of study quality vrs efficacy over time.

Part of my job is that of data synthesizer. What is the best way to treat, say, MRSA pneumonia? It can depend on many factors, some of which are not clear cut or have no data at all. Is the flu vaccine of benefit? The answer depends on what is considered a benefit and in what population; a single meta-analysis that looks at PCR-proven influenza will not include the effects on pregnancy, heart attack and stroke or the lack of spread to populations not vaccinated.

Whether or not a single study is superior or inferior to the collected wisdom of a systematic review depends on the question being asked and the plausibility of the intervention being studied.

I am not so certain that systematic reviews on fiction are a reliable way to understand the therapeutic efficacy of that fiction, but outside that caveat I agree with the authors conclusions: “It is time to focus on the entire body of evidence.”

And the body of evidence concerning most SCAM, as this blog demonstrates repeatedly, is there is no there there.

*Castagna.

Posted in: Clinical Trials, Medical Ethics, Science and Medicine

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39 thoughts on “Two Viewpoints

  1. windriven says:

    *Castagna.

    pfffft. Nouveau riche yuppie nirvana. ;-)

    Navarre. Better food at half the price and without the side order of pretension. Decent wines at a decent price too.

  2. windriven says:

    “Such sentiments are not uncommon…”

    It is well worth following Dr. Crislip’s link here*. It leads you to an item that discusses a survey of ~1250 registered voters. I was stopped in my tracks by this:

    “Forty-six percent said they did not believe there to be a link [between vaccines and autism].”

    That implies that 54 percent thought there was or might be a link – or, perhaps had no position on the matter. It is worth reading this in context and there are a variety of other bons mots scattered along the way. If that survey is truly representative it suggests that we are losing the battle in a rout. How many Crislips and Gorskis and Halls does it take to counter a B grade actress and a disgraced quack doctor?

    *http://www.raps.org/focus-online/news/news-article-view/article/3137/survey-of-americans-show-trust-in-big-pharma-only-slightly-above-faith-in-exist.aspx

    1. It’s like herd immunity. You need a critical mass. So it will take a lot (unfortunately).

  3. Jeffrey Rubinoff says:

    I still think Mark Twain in “Christian Science” described the utility of SCAM quite nicely. “Physicians cure many patients with a bread pill; they know that where the disease is only a fancy, the patient’s confidence in the doctor will make the bread pill effective.” But I don’t suppose you have many of the “worried well” in a hospital infectious disease practice.

  4. William Smith says:

    I have a daughter, going into 10 grade, that I am trying to introduce critical thinking to. She is very interested in science and I have her read articles such as this one. Can anyone recommend a blog or book, etc. that would be appropriate for her age and experience to introduce her to these concepts?

    1. windriven says:

      Great question. I contacted Grothe and Dunning a couple of years back asking the same question. I wanted to set up a program at the local high school and asked about resources available. Apparently there just isn’t much available – or at least wasn’t at that time – for elementary and high school students.

      1. goodnightirene says:

        Back in the Pleistocene, we were taught critical thinking as a unit of English class–sophomore year, I think. I was in Honors English, but I think the critical thinking unit was standard for everyone. There were lots of exercises with statements that had to be identified by their type of mistake, and we had to explain briefly, why the statement was, therefore, false. There was also a section that included the fallacies and tricks of advertising.

        Not that any of this has stopped gobs of people in my class from buying (figuratively and literally) the woo–but I have to think it has helped. :-/

      2. weing says:

        There is a board game called The Propaganda Game that I stumbled upon. It might still be available. Just google it.

      3. Chris says:

        This is why some parents who are professors at the local university set up a “Science Boosters” group. It does serve as an email list to recruit chaperones for field trips, but it did invite speakers for a once a month talk:
        http://www.rooseveltscience.org/index.html

        1. windriven says:

          Critical thinking in the context of science is wonderful starting point. Unfortunately, many never carry it to the rest of their lives.

    2. MedMarine says:

      There are some good introductory philosophy books aimed at kids and teens on Amazon (e.g. http://www.amazon.com/The-Examined-Life-Advanced-Philosophy/dp/1593630085/ref=pd_bxgy_b_img_z ). If she likes audio, maybe http://www.theskepticsguide.org/ ?

    3. Chris says:

      For one thing, you can recommend the books that have been reviewed on this site, often by Dr. Harriet Hall. I have also checked out of the library a “comic” book that discusses science and critical thinking by this tallguy: How to Fake a Moon Landing: Exposing the Myths of Science Denial (in the USA, in the UK: Science Tales).

      Other books I would suggest are:
      The Poisoners Handbook by Deborah Blum
      The Disappearing Spoon by Sam Kean
      Mr. Jefferson and the Giant Moose: Natural History in Early America by Lee Alan Dugatkin
      The Age of Wonder: The Romantic Generation and the Discovery of the Beauty and Terror of Science by Richard Holmes
      Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service by Mark Pendergrast

      Kinda okay (I am going through my spreadsheet of books): Lies, Damned Lies, and Science: How to Sort Through the Noise Around Global Warming, the Latest Health Claims, and Other Scientific Controversies by Sherry Seethaler

      1. Chris says:

        Crud. The italics did not work! Oh, well, you can tell there is a title and an author.

      2. Yodeladyhoo says:

        I wasn’t thinking of a 10th grade student when I read these, but some books I’ve really enjoyed recently are:

        The Ghost Map: The Story of London’s Most Terrifying Epidemic–and How It Changed Science, Cities, and the Modern World by Steven Johnson (the discovery of how cholera is spread)

        Scurvy: How a Surgeon, a Mariner, and a Gentlemen Solved the Greatest Medical Mystery of the Age of Sail by Stephen R. Bown (the cause of scurvy, with really good examples of how quack cures with no efficacy at all can retain their popularity for a long, long time)

        Charlatan: America’s Most Dangerous Huckster, the Man Who Pursued Him, and the Age of Flimflam by Pope Brock (It involves a guy who transplanted goat testicals into men complaining of impotence, so maybe not totally appropriate for a youngster, but quite a fascinating book about how gullible people can be and how shameless quacks can be)

        I enjoyed the Deborah Blum book mentioned above, but she made some factual errors which kind of spoiled it for me. I can’t remember what they were now. They were in details, not general principles.

        1. Chris says:

          Oh, Charlatan is great! It may also be of interest to a tenth grader for the introduction of the high power radio station.

          About Deborah Blum’s book: Oh, no! I was not aware of the errors. It would be interesting to see a blog post that pointed them out, there may be one from a chemist who blogs. I’ll try looking around.

    4. WilliamLawrenceUtridge says:

      You might try Robert Todd Carrol’s Skeptic’s Dictionary, which apparently now has a children’s version. It deals with concrete topics, it may be a bit early for the more abstract concepts (or not, I have no idea what 10-year-olds are like).

    5. Kerry Maxwell says:

      I think Carl Sagan’s “The Demon Haunted World” is age appropriate:
      http://en.wikipedia.org/wiki/The_Demon-Haunted_World

    6. Amanda says:

      I would also recommend Ken Feder’s Frauds, Myths and Mysteries: Science and Pseudoscience in Archaeology. Fantastic book and great overview of the scientific method and critical thinking.

  5. goodnightirene says:

    I like the new format! Much easier to read and I don’t have to resize at all. And a “reply” feature at last–Yay!

    Thanks for a nice, thought-provoking wind up to the week, Dr. C, and for the clarification of why personal experience is so useless. This comes up a lot when trying to explain to people why I don’t value their testimonies about sCAM.

  6. RobRN says:

    “…one in seven Americans think the pharmaceutical industry is colluding to “invent” new diseases in order to profit off them…”

    Well… I certainly know there are dozens of made up maladies in the CAM world like adrenal fatigue, systemic candidiasis, chronic lyme disease and Morgellons but who “invented” restless leg syndrome and fibromyalgia? There are drugs touted for those “diseases”.

    1. elburto says:

      Dr Frederick Wolfe invented/defined fibromyalgia in 1990. He now regrets it, especially as it has almost become an internet meme with what feels like every third netizen claiming to have it.

      Hilariously I recently ran across a website decrying him for his “belief” that it didn’t exist, and citing him, and people like him, as the reason people find the diagnosis so questionable. The author raged about how the disease was defined 23 years ago, so Dr Wolfe was out of line for disputing it. Very amusing.

      RLS was featured here at SBM or Neurologica recently though, and is a legitimate diagnosis.

      1. BrewandFerment says:

        Elburto, I posted this note on another article, either here or RI, and thought you’d be interested: Albany Medical College (Albany, NY) has used advanced imaging to identify an area of nerve dysfunction around the arteriole-venule shunts. Here’s a link if you are interested. I think it’s exciting that one of the more nebulous to diagnose diseases (at least in past history) is starting to reveal its workings.

        http://www.timesunion.com/default/article/Cure-for-painful-malady-is-closer-4588068.php

    2. BillyJoe says:

      Restless legs syndrome is real.
      My mother has a severe case for which nothing works.
      I have inherited a mild form that I can counteract with daily dynamic muscle stretching, which I discovered only coincidentally for myself and which, therefore, i do not recommend because it may not help anyone else. I would need to do a clinical trial first, but I am not a researcher, so it remains as an hypothesis with but a single piece of evidence in support.

  7. mcrislip says:

    Such a breath of fresh air. The redesign is almost everything I want: clean and easy to read and less cluttered.

    1. mho says:

      sorry, wasn’t sure if the name required was private or not
      I post under mho

  8. Well explained article.

    I’m curious about the frequency of use of “in my experience” in general medicine vs pain medicine. It is prevalent in dentistry!

    In my experience [;-)], the phrase is used to justify a lot of treatment that has little to no science in the hopes that the patient experiences at least some relief for some amount of time. I think this is why acupuncture (and other treatments) are so popular in pain-related conditions.

    I don’t personally agree with this approach but I don’t treat pain patients every day either.

    Perhaps the psychology of the pain practitioner is another blog post entirely…

    Thanks!

    1. goodnightirene says:

      I’ve often wondered how science-based dentistry is beyond the basics. Because I’ve moved a lot (and because I’m older), I’ve seen a lot of dentists and “in my experience”, as it were, if you describe the same problem to ten dentists, you will get ten different diagnoses. I refer to problems outside the obvious cavities or gum disease.

      For example, I asked at least five dentists about my teeth hurting when drinking hot coffee and got various (weird) answers or shrugs, until the newest guy instantly said, “sensitive teeth” and recommended the sensitive teeth toothpaste. Problem solved!

      Pot luck, “experience”, or science?

      I’ve also noticed a huge disparity in how long various dentists drill before filling a cavity! Some go on and on and on, while others are so quick, you wonder if they’ve done anything at all. And don’t get me started on endodontists!

    2. mattyp says:

      Sometimes I have used “in my experience” because patients aren’t interested when I say “well the literature/evidence says”, they want me to use my best clinical judgement based on experience. Now, it “in my experience” for me, means 1) what I have learnt at university, 2) what I have read in the literature, and 3) my clinical experiences with cases. The patient doesn’t care that’s what it means. There’s no harm in saying “in my experience” to a patient so long as you are being clear and true to yourself why you are choosing a particular diagnostic test/intervention or not.

  9. adamantinequill says:

    “But what if your whole practice is based on bias, on unreality, and you cannot realize it? The only bias you can alter is to convince your patients is that real medicine is fantasy and that fantasy is reality. Welcome to the Natural News, the bizarro world of medicine.”

    That is a nice philosophical summation of the problem of so many alternative realities & also a pretty good description of how most advertising works. :-)

    Thanks as always for a good Friday read.

    Cordially,
    Quill (new username for the old usual reasons)

  10. Ivan says:

    The title doesn’t tell me what the post is about, neither do the first 2 paragraphs and it isn’t short either.

    1. goodnightirene says:

      I think it’s called “introduction”. If all is explained in the first paragraph, why would there be a third paragraph?

    2. elburto says:

      #firstworldproblems

  11. Carl says:

    To believe a single study is to believe anything you hear.
    To believe a meta-analysis is to believe everything you hear.

  12. wolf 10 says:

    test

  13. pmoran says:

    Where CAM is concerned the “ethics of persuasion” will surely depend mainly upon the soundness of the science being applied, especially when there is any potential for real patient benefits or for a reduction in medicine’s unavoidable undercurrent of risk.

    If sound information is offered, and delivered with the normally cautious and precise language of authentic medical science, ethical questions can hardly arise.

    This is where we could be more careful, in my opinion. We sometimes talk in ways that only seem right to us because they are customary within our specific circle. They may have arguable concordance with the evidence, and be less apt for other ears.

    We have just now been hearing (again) how acupuncture is a useless medical intervention — period. In one of those posts comfort was derived from the “strongly against” recommendation of that not renownedly scientifically sophisticated authority, the American Association of Surgeons. .I am not the only one to be a little startled by the strength of the language in that piece — e.g. “there is strong evidence against –”.

    It prompts me to refer to an earlier caution of mine —

    Quote–

    If acupuncture provided pain relief anywhere vaguely comparable to narcotics, you might have the beginnings of an argument there.

    ——– don’t forget that the apparently beneficial effects of acupuncture can often be demonstrated over and above those of regular medical care and in otherwise difficult and disabling conditions such as chronic pain. They are also only small (e.g. effect sizes of about 0.25) when you consider comparisons with sham variants, not when you compare acupuncture variants including sham with usual care (effect sizes of 0.4-0.5).

    Also, who is to say that even small gains are not worthwhile to some? If we are going to attack the paternalistic judgements of others, we should be careful. . The most we can do is advise on their likely cost-effectiveness to those for whom that is a major consideration. But we might need a lot more data for that, also more certainty as to either the actuality or illusoriness of the apparent benefits.

    This is also before considering that the “small gains” derive from averaging out in an artificial clinical environment.

    Unquote.

    Note –

    1. this in no way supports ancient Chinese medical theory. Some of the more suggestive studies regard acupuncture as a kind of complex psycho-socio-sensory intervention (e.g. http://rheumatology.oxfordjournals.org/content/46/3/384.short )

    2. I am not overlooking the potential for bias in these studies. There is undoubtedly an admixture of influences within which the contribution of true patient benefits (or lack thereof) is uncertain . That is the point. It is not even clear that being biased cannot translate into less suffering.

    3. I do not have a “thing” about acupuncture. The same considerations would apply to any program of similar influences.

  14. George says:

    It’s kind of freaky to think that one in seven Americans think that pharmaceutical companies are out to get them. As you point out in your article, though, it’s hard to change that bias against the companies once they have it. A person believes their own words much more than they believe the words of others.

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