Vacation then taxes have consumed my focus the last two weeks, and I have had little time to devote to issues of infectious diseases, much less SBM, so I will instead meander around a more philosophical terrain.  I feel guilty when I do not have a substantive, data driven post evaluating a paper or essay in detail, but some weeks there just is not the time.

Being involved with SBM has been, like all intellectual endeavors, a process rather than result. I keep experimenting with conceptual frameworks with which I can understand the differences between a SBM approach and a SCAM (supplements, complementary and alternative medicine) approach. Nothing clarifies thoughts quite like writing them down. Or maybe not.

The motto of the blog is “exploring the relationships between science and medicine” but it is often more about non-overlapping boundaries* than relationships. We are often separated more by Berlin walls than Venn diagrams.

There are perhaps four boundaries that separate science-based medicine from those who prefer SCAMs. More if you are a splitter; I am a lumper by nature. At work I am an Occam kind of guy.

One boundary separates reality from fantasy. Reality is defined by the description of the natural world provided by the sciences. This blog keeps pounding away at the wall, with remarkably little effect. Be it anti-evolution, anti-vaccine or any other non-reality-based world view, they appear immune to the facts.

It is weird, and it took me a long time to realize that for many people facts are just not important. For 30 years I have worked in medical teaching institutions where facts are important. I see a patient where the intern has treated a methicillin susceptible S. aureus bacteremia with a short course of IV vancomycin and then changed the patient to oral clindamycin. I see a similar case or two at the start of almost every academic year. I go though all the permeations of S. aureus infections and the antibiotics used to treat them, going through all the clinical trials to justify my conclusions. Just the facts ma’am.

And when we are done the intern will not do THAT again. Trust me. No one wants to sit through me talking about S. aureus more than once in a career. But in medicine the facts change what we do. Eventually. That never seems to be the case in the SCAM world. It took me years to understand that although my blog entries often focus on the facts of a topic, reality as I understand it, for many, if not most in the SCAM community, facts do not matter. Facts only serve to support a predetermined world view, not alter it.

This month an article was published by the CDC looking at whether autism is caused by too many vaccines in too short a time, the “too much too soon” hypothesis. Dr. Gorski covered it a few days ago.

From basic principles one would not expect the paltry number of antigens in vaccines to be associated with autism, and the study suggests there is NO relationship between the number of vaccines and the development of autism.

I was looking forward to an essay at Age of Autism with the title: “We were wrong. Too many too soon is a failed hypothesis.” I should also look forward to an end to global warming and increased Medicare reimbursements.

To my knowledge, those who are the topics of this blog never change their beliefs as a result of high quality medical studies, which is hard to do even if you are not emotionally invested in the concepts studied. The longer I practice medicine the more effort it takes to practice differently based on new information. In the SCAM world they are immune to reality-based change, which, in the case of anti-vaccine proponents, is a curious phraseology.

Another boundary is philosophical/political/moral. It is a weird wall that separates us. I can understand the wish to be free to make your own decisions about your health care. What I can’t wrap my head around is the conspiratorial nature of many of the comments on this and other blogs. That there is a cabal of Government, pharmaceutical companies and doctors conspiring to hide the truth from people. And we do it because we are not only greedy, profiting from the medical-industrial complex, but we have evil motives. We are bad guys.

It is a world view that I overheard on vacation. I was wandering around a jewelry shop in Santa Fe and I overheard a customer telling the poor cashier that “they know what causes cancer and how to cure it, but there is too much money in the status quo.”

I do not know how common that world view is, which to my mind is as fantastical as the precepts of homeopathy, but it is a loud one. The conspiracy is always the last refuge of those who cannot accept the findings of science, as Orac points out:

They would never publish a study showing vaccines cause autism.

Sure they would. That’s what the CDC does. That is what they have done and always will do.

I do not comprehend the conspiratorial approach to the world. I tend to see most people in health care, real and alternative, as doing what they think is the right thing for people. I do not see SCAM proponents as evil, just misguided. They certainly do not see SBM in the same way.

Another boundary is in understanding that the fundamental flaws in thinking that define human behavior, the logical fallacies, apply to everyone all the time: me, you, all of us. Most of the time proponents of SCAMs fail to comprehend my favorite observation by Richard Feynman:

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

It is odd that those us of at SBM may have the adjective “arrogant” applied to us, but I think we are just the opposite. We are all too aware of the numerous ways we can think poorly and be fooled. That ability seems lacking in proponents of SCAM.

So often when reading a study that allegedly demonstrates efficacy of one SCAM or another there are flaws that allow the researcher or the patient to fool themselves. It is remarkable how often these flaws go unnoticed.

The final boundary is not realizing that the usual standards by which we evaluate the medical literature do not apply when evaluating the alleged effects of SCAMs. The rules of engagement are slightly different for reality- than for fantasy-based interventions.

Studies of the effects homeopathy or reiki or acupuncture are not evaluations of a therapeutic intervention that has an effect on an anatomic structure or a physiologic process. They are best seen as elaborate psychological evaluations of the reaction of people to complicated artificial rituals. They are medical equivalent of the Stanford prison experiment where patient and doctor follow explicit and subtle cues to behave as if something is occurring that could alter a disease.

When evaluating nonsense in a clinical trial, are you doing science? Yes, just not good science. If the principals you are studying are based on fantasy, like homeopathy or chelation, it is mummery of science; it is tooth fairy science.

I was struck this week by a quote of one of the TACT investigators and their inability to recognize in TACT tooth fairy science combined with methodological flaws, as the flaws were noted by skeptics:

“Although skepticism has an important role to play in critical debates, it is easy to overplay that hand. The people you mention seem to have a very naïve view of science, very far removed from the messy realities of daily work of people doing science. It is also important to remember that even the most hard core scientists can have some pretty eccentric views when they venture outside their narrow field of expertise. What does that imply about science and the people who wish to guard its borders?

There has been a project in philosophy to identify firm demarcation criteria that will allow for a distinction between science and pseudoscience. While some useful work has resulted, the overall attempt failed. Gets into some deep waters, but the harder the philosophers tried to find that electrified fence that marked off “real science” from the rest of human thought, the more they undermined the borders of science itself. Interestingly, “real scientists” rarely worry about whether they are doing science. They consider the question uninteresting, leaving it for the philosophers, sociologists and (now) the bloggers!”

For three years as a fellow I tried being a “real scientist”, involved with investigating the interactions of Candida and endothelial cells and what made the former adhere to the latter. I was involved in a clinical trial using anti-endotoxin antibody to modify the course of sepsis. I was the Peter Principal personified. It is with good reason I am a clinician.

In those days I never worried whether I was doing science, because Candida and endothelial cells are tangible, as are endotoxin and antibodies.

I did not try to generate adherence negative Candida mutants with N-Ray’s; I used UV. I did not suppress bacteria in the endothelial cultures with homeopathy, I used antibiotics. I did not try to alter the pathophysiology of sepsis by altering qi, I tried to inactivate bacterial endotoxin.  I kept within the bounds of reality.

The question is not whether “real scientists” are doing “real science” but are they doing good science: careful evaluation of complex, and real, phenomena where potential biases and flaws are known and controlled for.

When you study a real intervention against a real phenomena, you need not worry quite as much about the potentially confounding issues raised by fantasy. When you are studying nonsense as if it were real, those potentially confounding biases become of paramount importance.

What skeptics recognize are “the messy realities of daily work of people doing science” especially as they apply to the scientific evaluation of fantasy-based therapies. Just as the best investigator for psychic powers is a magician, not a physicist, the best critic of a study of nonsense is a skeptic. We are experienced in recognizing the errors that most people either do not consider or fail to apply to themselves.

It is an ongoing curiosity how real scientists become blind to the confounding flaws and even reality when they study SCAMs.  So many, where read carefully, are all sound and fury signifying nothing.

There many boundaries between SBM and SCAM. They all seem thicker and taller than when I started blogging years ago. Then I thought all that people needed to know was the difference between reality and fiction.  A wee bit of education. Let them know why this SCAM or that is nonsense and they would say “oh, I see” and we could all move on. Naïve and simplistic, I know. But that is the story of all my intellectual endeavors. The more I know, the more complicated it becomes.

Sisyphus had it easy.

*no way am I going to say Non-overlapping magisteria ; je déteste ça.

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