Here is yet another study claiming to show “how acupuncture works” when in fact it does nothing of the kind. It does, however, reveal the bias of the researchers – it is, in fact, surprising that it was published in a peer-reviewed journal. Unfortunately, the mainstream media is dutifully reporting the biased claims of the researchers without any independent verification or analysis.
There are numerous fatal problems with this study. The first, like in many physiological studies that purport to be about acupuncture, is that the connection to acupuncture is tenuous. The researchers claim that they are testing the effects of an acupuncture needle – but what makes a needle an acupuncture needle? Other such studies were ultimately just seeing the effects of local tissue trauma. The fact that this trauma was induced by an “acupuncture needle” is not necessarily relevant.
This study is far worse, because it is simply using the acupuncture needle as a mechanism for inducing an unrelated physiological stimulus. This is similar to “electroacupuncture” where electrical current is applied through an acupuncture needle – what you are actually studying is the effects of electricity, not “acupuncture.” Applying electrical stimulation, or some other physiological stimulus, is the equivalent of injecting morphine through a thin needle and then claiming this demonstrates how “acupuncture works.”
The fundamental concept of science-based medicine (SBM) is that medical practice should be based upon the best available science. This may seem obvious, but there are many important details to its application, such as the relationship between clinical and basic science. Clinical claims require clinical evidence, but clinical evidence can be tricky and is often preliminary. It is therefore helpful (I would say essential) to view the clinical evidence in light of all of the rest of science.
A thorough basic and clinical science analysis of a medical claim can be summarized by the term “plausibility,” or “prior probability” if you want to put it into statistical terms. When we say a certain belief is plausible we mean it is consistent with what we know from the rest of science. In other words, because of the many weaknesses of clinical evidence, in order for a therapy to be generally accepted as part of SBM it should have a certain minimal supporting clinical evidence and overall scientific plausibility.
These can exist in different proportions – for example one therapy may be highly plausible (it would be shocking if it were not true) and have modest supporting clinical evidence, while another may have unknown plausibility but with solid clinical evidence of efficacy. But no therapy should have clinical evidence that suggests lack of efficacy, nor extreme implausibility (not just an unknown mechanism, but no possible mechanism).
There have been many cases now of big companies or organizations, or wealthy individuals, threatening to sue or actually suing a blogger for libel. The most famous case is that of Simon Singh who was sued by the British Chiropractic Association over comments he made in an article. Simon braved through the expensive and exhaustive legal process (which is especially onerous in England), but he is not just a lone blogger. He is a successful author and was writing for the Guardian. Eventually the BCA was forced to drop the case – but only after the blogging community rallied behind Simon, magnifying his criticisms of the BCA by orders of magnitude. By all accounts it was a PR disaster.
The blogging community as a whole is rather passionate about this issue. We exist on the premise of free and open public discourse about important issues. At SBM we take on many controversial issues and we don’t pull our punches when criticizing what we see as pseudoscience in medicine. So of course we take notice when a large company tries to bully a blogger to silence their legitimate criticism.
According to the BMJ this has happened yet again – this time the international homeopathy producer, Boiron, is threatening a lone Italian blogger because he dared to criticize their product, Oscillococcinum. The blogger, Samuele Riva, wrote two articles on his blog, blogzero.it, criticizing what our own Mark Crislip has called “oh-so-silly-coccinum.” The blog is entirely in Italian, but he is maintaining a page in English with updates on the Boiron vs Blogzero affair.
In 1994 Congress (pushed by Senators Harkin and Hatch) passed DSHEA (the Dietary Supplement Health and Education Act). As regular readers of SBM know, we are not generally happy about this law, which essentially deregulated the supplement industry. Under DSHEA supplements, a category which specifically was defined to include herbals, are regulated more like food than like medicinals.
Since then the flood-gates opened, and there has been open competition in the marketplace for supplement products. This has not resulted, I would argue, in better products – only in slicker and more deceptive claims. What research we have into popular herbals and supplements shows that they are generally worthless (except for targeted vitamin supplementation, which was already part of science-based medicine, and remains so).
A company can essentially put a random combination of plants and vitamins into a pill or liquid and then make whatever health claims they wish for their product, as long as they stay within the “structure-function” guidelines. This means they cannot claim to cure or treat a specific disease, but this has proven to be an insignificant limitation on marketing supplements.
Part of the Complementary and Alternative Medicine (CAM) movement is an attempt to insert spirituality into the philosophy and practice of medicine. Most energy healing modalities, for example, have spiritual underpinnings. At the same time there are many attempts to use science to validate the healing power of faith. This is also an issue that is very attractive to the media, who love articles and headlines about the power of prayer. In our culture – faith sells.
A recent article in the Detroit Free Press is an excellent example of bad reporting and the sensationalizing of this issue. It does a good job of maximally confusing the issue.
To be clear, SBM is not anti-faith or anti-religion. But the issue of faith in medicine raises two main areas of concern. The first is the misrepresentation of the scientific evidence, both for intercessory prayer and the health effects of faith. The second are the ethical and professional implications of mixing faith with medical practice.
The Detroit Free Press article makes no attempt to distinguish the various issues with faith and medicine, and confuses them together in a misleading way. Intercessory prayer is, essentially, praying for the health of another person. There have been about a dozen such trials with reasonable design. In most the subjects know they may be prayed for. But of course, none of the trials can control for those who are not part of the study praying for a study subject.
One of the basic human “needs” is the desire for simplicity. We have limited cognitive resources, and when we feel overwhelmed by complexity one adaptive strategy is to simplify things in our mind. This can be useful as long as we know we are oversimplifying. Problems arise when we mistake our schematic version for reality.
In this same vein we also like our narratives to be morally simple, so there is a tendency to replace the complex shades of gray with black and white. This is perhaps related to cognitive dissonance theory. We have a hard time reconciling how someone can be both good and bad, or how a good person can do bad things. So there is also a tendency to see people as all good or all bad. We can transcend these tendencies with maturity and wisdom, but that takes work.
A good example of the desire for simple moral clarity is the anti-vaccine movement. Their world is comprised of white hats and black hats (guess which one they perceive themselves as wearing), as evidenced by the blog posts and comments over at Age of Autism. There is a certain demand for purity of thought and message that seems to be getting worse over time in a self-reinforcing subculture. Many now see their struggle in apocalyptic terms.
As health care costs rise and great attention is being paid to the health care system in many countries (perhaps especially the US), the debate is heating up over how to improve public health. Many health problems are greatly increased by the lifestyle choices individuals make – smoking, weight control, and exercise to name a few. The problem is that it is notoriously difficult to change behavior.
There are different ways to approach the challenge of improving lifestyle choices to reduce chronic illness. We can take actions aimed at the individual or aimed at society. These actions can be gentle or passive (the so-called “nudge theory”), or they can be more draconian, such as banning certain activity. We can, of course, do all of these things simultaneously, and may need to in order to have a significant impact.
Affecting Individual Behavior
A common criticism of mainstream physicians is that they do not have much impact on the lifestyle of their patients. This is largely true – although there is no convincing evidence that any practitioners have a significant impact on lifestyle. This is mainly the result of the fact that it is extremely difficult to get people to change their behavior.
Many of the SBM blogger are at The Amazing Meeting 9 this week – or TAM9 From Outer Space, as it is whimsically called. The JREF, who sponsors TAM, is a big supporter of our efforts at SBM and, in fact, as of this year co-sponsors this blog along with the New England Skeptical Society (both non-profits).
This year, as with the last two TAMs, there will be a workshop on SBM. The topic is, “Oh no, not again! – Recurring themes in medical mythology.” David Gorski, Kimball Atwood, Harriet Hall, Mark Crislip and I decided to discuss the most common recurrent themes in unscientific or philosophy-based medicine (which is much of what passes for CAM). The core idea of the workshop is that the same basic themes keep cropping up again and again in CAM modalities. They may contain slight variations on the basic theme, but mostly are just the same thing with a different superficial window dressing.
So, for example, many systems are based upon the common theme of “energy medicine” – the notion that there is a life force or life energy that is responsible for health, and blockages in the flow or power of this energy cause “unwellness.” Modalities as apparently distinct as straight chiropractic, acupuncture, and Reiki are all based on this pre-scientific idea.
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.
Over the last week I have received numerous questions about a recent study (yet to be published, but highly publicized in the press) in which it is claimed that the application of a magnetic field can improve blood flow. Physics World declared in the headline that, “Magnetic fields reduce blood viscosity.” This is not a bad summary of the study, but then the first sentence claims:
Researchers in the US claim that exposing a person to a magnetic field could reduce their risk of a heart attack by streamlining the flow of blood around their body.
Science Magazine ran with the also tame headline of “Magnets Keep Blood Flowing” but also had some problems in the text of their report (which I will get to).
The amount of press attention the study is getting is a bit odd. It’s a small proof-of-concept study looking at the effects of strong magnetic fields on blood flow in vitro. I suspect part of the reason is the same as why so many people have been asking me about it – magnets are frequently marketed with health claims and these claims are often justified by the hand-waving explanation that magnetic fields improve blood flow. The concern is that this small study will be abused by huxsters to sell refrigerator magnets with unfounded health claims.