Here’s an interview I recorded a while back that’s shown up on the Michigan Skeptics website. Check out Adam’s Song: Episode 5 of the Drunken Skeptics Podcast. It was a fun and interesting discussion…
The last couple of weeks, I feel as though I may have been slumming a bit. After all, comparatively speaking it’s not that difficult to take on claims that homeopathy benefits fibromyalgia or Oprah Winfrey promoting faith healing quackery. Don’t get me wrong. Taking on such topics is important (otherwise I wouldn’t do it). For one thing, some quackery is so harmful and egregiously anti-science that it needs to be discussed. For another thing, they serve as examples of how even the most obvious quackery can seem plausible. All it takes are the cognitive quirks to which all humans are prone plus a bit of ignorance about what constitutes good scientific evidence to support the efficacy of a given therapy for a given condition.
So let’s move on to something a little more challenging.
Of all the attacks on science-based medicine (SBM), one of the favorite attacks made by its opponents is the claim that SBM is dangerous, that it kills or harms far more people than it helps. An excellent example of this occurred when quackery promoter Joseph Mercola teamed up with fellow quackery promoter Gary Null to write a widely cited article entitled Death by Medicine. Using the famous Institute of Medicine article that estimated deaths from medical errors to be on the order of 50,000 to 100,000 per year, Mercola and Null wove a scary story meant to imply that conventional medicine does far more harm than good. Of course, as our very own Harriet Hall pointed out, they concentrated solely on the harm, which makes it difficult to determine whether the harms truly outweigh the benefits. As Peter Lipson puts it, such arguments are intentionally designed to take our fears and exaggerate them out of all perspective. The idea behind the fallacious arguments used by the likes of Mercola and Null is that, because “conventional” medicine has problems and needs to improve its safety record, the quackery they promote must be a viable alternative to SBM. Yes, that is basically what their arguments boil down to.
The fallacious manner in which advocates for quackery such as Joe Mercola, Mike Adams, and Gary Null use and abuse any shortcoming of SBM that they can find (and, when they can’t find any, make some up) notwithstanding, there is a problem in SBM. Indeed, over the last 10 years or so since the IOM report, reducing the toll due to medical errors has — finally — become an incredibly important issue in medicine. Indeed, I myself have become involved in a state-wide quality improvement initiative in breast cancer as our site’s project director. As a result, I’m being forced to learn more about the nitty-gritty of quality improvement than I had ever thought I would. Combine this with a study published just before the Thanksgiving holiday in the New England Journal of Medicine, and I’m learning that improving care is incredibly difficult. The issues involved are many and tend to involve systems rather than individuals, which is why the solutions often bump up against the individualistic culture to which physicians belong. Moreover, such efforts, like comparative effectiveness research (CER), tend to earn less prestige than scientific research because, like CER, quality improvement initiatives do not in general look for new information and scientific understanding but rather at how we apply what we already know.
It’s Thanksgiving Day here in the U.S., and, despite the crappy economy, there are still things to be thankful for. For instance, skeptical activism can still be effective. On Sunday Skepchick Elyse put out the call to Skepchick readers to complain to movie theaters that were reportedly going to be airing a public service announcement from the anti-vaccine group SafeMinds? (Actually, “public service announcement” is a misnomer; it should be called a public disservice announcement.) The entire PSA was a truly disgusting and deceptive bit of misinformation. In response, Elyse urged Skepchic readers to flood the relevant theaters with complaints about showing an anti-vaccine advertisement prior to its movies.
Now here’s what we can be thankful for: It worked. At least with AMC Theaters. Last night the anti-vaccine propaganda blog Age of Autism, which had been teaming up with SafeMinds to raise money to show these ads during the Thanksgiving holiday weekend admitted as much.
SafeMinds was notified late yesterday afternoon that AMC Theaters has decided to block the SafeMinds Public Service Announcement (PSA) on influenza vaccines with mercury. The PSA alerts parents and pregnant women of the presence of mercury in most influenza vaccines and the ample availability of mercury-free alternatives. The CDC has declined to give a preference for the mercury-free versions, so it is important that the public is aware of its options. AMC’s advertising representative had reviewed and approved the PSA to run in AMC cinemas over the Thanksgiving weekend. A small group of vocal vaccine proponents dismissive of mercury concerns learned of the PSA and bombarded the AMC website, leading to the company’s decision to prevent its release. SafeMinds thanks its supporters who viewed the PSA and contributed to its efforts to educate the public to avoid unnecessary mercury exposure. Mercury in all forms is dangerous, especially to the developing fetus and infants, as referenced on the PSA website www.safemindsflu.org. SafeMinds will continue its mission to educate the public on this important healthcare topic.
Several of the bloggers on Science-Based Medicine have been — shall we say? — rather critical of Oprah Winfrey. The reason, of course, is quite obvious. Oprah is so famous that if you mention her first name nearly everyone will know exactly of whom you speak. For the last quarter century, her daytime TV talk show has been a ratings juggernaut, leading to the building of a media behemoth and making Oprah one of the richest and most famous women in the world. Unfortunately, part of Oprah’s equation for success has involved the promotion of quackery and New Age woo, so much so that last year I lamented about the Oprah-fication of medicine, which scored me a writing gig in the Toronto Star. Whether it be promoting bio-identical hormones, The Secret (complete with a testimonial from someone who used The Secret to persuade herself not to pursue conventional therapy for breast cancer), Suzanne Somers, the highly dubious medicine promoted by Dr. Christiane Northrup, or foisting reiki aficionado Dr. Mehmet Oz or anti-vaccine “mother warrior” Jenny McCarthy onto a breathless public, arguably no one is a more powerful force for the promotion of pseudoscience in America, if not the world. Truly, the ending of Oprah’s TV show in the spring is a very good thing indeed for science and rationality. Or it would be, were it not for the fact that the reason Oprah is wrapping up her show after a quarter of a century is to start up her own cable channel, so that we can have Oprah-branded and -inspired programming 24/7.
The mind boggles.
Still, my dislike for how Oprah promotes New Age mysticism and pseudoscience on a distressingly regular basis aside, I actually did think there were limits to how low she would go. I actually thought there were limits to how egregiously vile a quackery Oprah would endorse. The operative word, of course, is “did,” which now needs to be struck off after last Wednesday, which is when Oprah did an entire show entitled Do You Believe in Miracles? (Guess what answer was implicitly, if not explicitly, endorsed.) Featured prominently in that episode were several segments on the faith healer John of God.
Over the weekend, my wife and I happened to be in the pharmacy section of our local Target store. We happened to be looking for one of our favorite cold remedies, because both of us have been suffering from rather annoying colds, which have plagued both of us for the last week or two. As we perused the Cold and Flu section of the pharmacy, we were struck at how much shelf space was taken up by Airborne (which was “invented by a schoolteacher“). Nearly three years ago Airborne had to settle a case brought against it alleging false advertising to the tune of $23 million. Despite that, Airborne is still being sold, and there are even a whole bunch of knock-off products copying it. Then, as we continued to look for our favored cold remedy, we noted that, sitting right next to the extensive shelf space devoted to the various flavors and types of Airborne supplements, I saw Boiron’s homeopathic remedy for colds containing oscillococcinum, which is derived from duck liver and heart and diluted to 200C (a 10400-fold dilution).
Yes, I was a bit depressed after that. Now I know what my skeptical friends in the U.K. go through every time they walk into a Boots pharmacy.
Integrating patient experience into research and clinical medicine: Towards true “personalized medicine”
We advocate science-based medicine (SBM) on this blog. However, from time to time, I feel it necessary to point out that science-based medicine is not the same thing as turning medicine into a science. Rather, we argue that what we do as clinicians should be based in science. This is not a distinction without a difference. If we were practicing pure science, we would be theoretically able to create algorithms and flowcharts telling us how to care for patients with any given condition, and we would never deviate from them. It is true that we do have algorithms and flowcharts suggesting guidelines for care for a wide variety of conditions, but there is wide latitude in them, and often a physician’s “judgment” still ends up trumping the guidelines. While it is also true that sometimes physicians have an overinflated view of the quality of their own “clinical judgment,” sometimes to the point of leading them to reject well-established science, as Dr. Jay Gordon frequently does, what I consider to be physician’s judgment is knowing how to apply existing medical science to individual patients based on their circumstances and, yes, even desires and values.
Indeed, if there’s one area where SBM has all too often fallen short in the past, it’s in taking into account the patient’s experience with various treatments. What got me thinking (again) about this issue was an article by Dr. Pauline Chen in the New York Times last Thursday entitled Listening to Patients Living With Illness. She begins her article with an anecdote:
Attacks on science-based medicine (SBM) come in many forms. There are the loony forms that we see daily from the anti-vaccine movement, quackery promoters like Mike Adams and Joe Mercola, those who engage in “quackademic medicine,” and postmodernists who view science as “just another narrative,” as valid as any other or even view science- and evidence-based medicine as “microfascism.” Sometimes, these complaints come from self-proclaimed champions of evidence-based medicine (EBM) who, their self-characterization otherwise, show signs of having a bit of a soft spot for the ol’ woo. Then sometimes there are thoughtful, serious criticisms of some of the assumptions that underlie SBM.
The criticism I am about to address tries to be one of these but ultimately fails because it attacks a straw man version of SBM.
True, the criticism of SBM I’m about to address does come from someone named Steve Simon, who vocally supports EBM but doesn’t like the the criticism of EBM implicit in the very creation of the concept of SBM. Simon has even written a very good deconstruction of postmodern attacks on evidence-based medicine (EBM) himself, as well as quite a few other good discussions of medicine and statistics. Unfortunately, in his criticism, Simon appears to have completely missed the point about the difference between SBM and EBM. As a result, his criticisms of SBM wind up being mostly the application of a flamethrower to a Burning Man-sized straw man representing what he thinks SBM to be. It makes for a fun fireworks show but is ultimately misdirected, a lot of heat but little light. For a bit of background, Simon’s post first piqued my curiosity because of its title, Is there something better than Evidence Based Medicine out there? The other reason that it caught my attention was the extreme naiveté revealed in the arguments used. In fact, Simon’s naiveté reminds me very much of my very own naiveté about three years ago.
Here’s the point where I tell you a secret about the very creation of this blog. Shortly after Steve Novella invited me to join, the founding members of SBM engaged in several e-mail frank and free-wheeling exchanges about what the blog should be like, what topics we wanted to cover, and what our philosophy should be. One of these exchanges was about the very nature of SBM and how it is distinguished from EBM, the latter of which I viewed as the best way to practice medicine. During that exchange, I made arguments that, in retrospect, were eerily similar to the ones by Simon that I’m about to address right now. Oh, how epic these arguments were! In retrospect, I can but shake my head at my own extreme naiveté, which I now see mirrored in Simon’s criticism of SBM. Yes, I was converted, so to speak (if you’ll forgive the religious terminology), which is why I see in Simon’s article a lot of my former self, at least in terms of how I used to view evidence in medicine.
The main gist of Simon’s complaint comes right at the beginning of his article:
I have been very, very remiss about this, but I totally forgot to pimp my appearance a week and a half ago on Skeptically Speaking. Part of the reason was that I tend to be rather shy about interviews, and part of the reason was that I just plain forgot. Given our having dedicated this week to the discussion of vaccines on Science-Based Medicine, I thought it would be the perfect time to point out to Skeptically Speaking #82 Vaccines.
We write a lot about vaccines here at Science-Based Medicine. Indeed, as I write this, I note that there are 155 posts under the Vaccines category, with this post to make it 156. This is third only to Science and Medicine (which is such a vague, generic category that I’ve been seriously tempted to get rid of it, anyway) and Science and the Media. There is no doubt that vaccines represent one of the most common topics that we cover here on SBM, and with good reason. That good reason is that, compared to virtually any other modality used in the world of SBM, vaccines are under the most persistent attack from a vocal group of people, who, either because they mistakenly believe that vaccines caused their children’s autism, because they don’t like being told what to do by The Man, because they think that “natural” is always better to the point of thinking that it’s better to get a vaccine-preventable disease in order to achieve immunity than to vaccinate against it, or because a combination of some or all of the above plus other reasons, are anti-vaccine.
“Anti-vaccine.” We regularly throw that word around here at SBM — and, most of the time, with good reason. Many skeptics and defenders of SBM also throw that word around, again with good reason most of the time. There really is a shocking amount of anti-vaccine sentiment out there. But what does “anti-vaccine” really mean? What is “anti-vaccine”? Who is “anti-vaccine”?
Given that this is my first post for SBM’s self-declared Vaccine Awareness Week, proposed to counter Barbara Loe Fisher’s National Vaccine Information Center’s and Joe Mercola’s proposal that November 1-6 be designated “Vaccine Awareness Week” for the purpose of posting all sorts of pseudoscience and misinformation about “vaccine injury” and how dangerous vaccines supposedly are, we decided to try to coopt the concept for the purpose of countering the pseudoscience promoted by the anti-vaccine movement. To kick things off, I thought it would be a good idea to pontificate a bit on the topic of how to identify an anti-vaxer. What makes an anti-vaxer different from people who are simply skeptical of vaccines or skeptical of specific vaccines (for instance, the HPV vaccine)? I don’t pretend to have the complete answer, which is why I hope we’ll have a vigorous discussion in the comments.
I realize that in the question-and-answer session after my talk at the Lorne Trottier Public Science Symposium a week ago I suggested in response to a man named Leon Maliniak, who monopolized the first part of what was already a too-brief Q&A session by expounding on the supposed genius of Royal Rife, that I would be doing a post about the Rife Machine soon. And so I probably will; such a post is long overdue at this blog, and I’m surprised that no one’s done one after nearly three years. However, as I arrived back home in the Detroit area Tuesday evening, I was greeted by an article that, I believe, requires a timely response. (No, it wasn’t this article, although responding to it might be amusing even though it’s a rant against me based on a post that is two and a half years old.) Rather, this time around, the article is in the most recent issue of The Atlantic and on the surface appears to be yet another indictment of science-based medicine, this time in the form of a hagiography of Greek researcher John Ioannidis. The article, trumpeted by Tara Parker-Pope, comes under the heading of “Brave Thinkers” and is entitled Lies, Damned Lies, and Medical Science. It is being promoted in news stories like this, where the story is spun as indicating that medical science is so flawed that even the cell-phone cancer data can’t be trusted:
Let me mention two things before I delve into the meat of the article. First, these days I’m not nearly as enamored of The Atlantic as I used to be. I was a long-time subscriber (at least 20 years) until last fall, when The Atlantic published an article so egregiously bad on the H1N1 vaccine that our very own Mark Crislip decided to annotate it in his own inimitable fashion. That article was so awful that I decided not to renew my subscription; it is to my shame that I didn’t find the time to write a letter to The Atlantic explaining why. Fortunately, this article isn’t as bad (it’s a mixed bag, actually, making some good points and then undermining some of them by overreaching), although it does lay on the praise for Ioannidis and the attacks on SBM a bit thick. Be that as it may, clearly The Atlantic has developed a penchant for “brave maverick doctors” and using them to cast doubt on science-based medicine. Second, I actually happen to love John Ioannidis’ work, so much so that I’ve written about it at least twice over the last three years, including The life cycle of translational research and Does popularity lead to unreliability in scientific research?, where I introduced the topic using Ioannidis’ work. Indeed, I find nothing at all threatening to me as an advocate of science-based medicine in Ioannidis’ two most famous papers, Contradicted and Initially Stronger Effects in Highly Cited Clinical Research and Why Most Published Research Findings Are False. The conclusions of these papers to me are akin to concluding that water is wet and everybody dies. It is, however, quite good that Ioannidis is there to spell out these difficulties with SBM, because he tries to keep us honest.