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The Fog of Medicine

Pictured: Medicine. In space!

Pictured: Medicine. In space!

I often get called on to be a diagnostician. The referring doctor is uncertain what is going on in the patient, often a fever of unknown origin, and they call me to help figure it out. Sometimes I do, sometimes I don’t.

Making the correct diagnosis is not easy, even after 35 years. The classic phrase is the fog of war, but the fog of medicine is equally confusing. In retrospect sometimes a diagnosis becomes clearer, but in real time? It is so easy to be wrong and so difficult to be correct.

I remember the first case of my career. A patient developed neutropenia (low white count) from a sulfa antibiotic and over the next two weeks went into multi-organ system failure and died. At autopsy it was discovered that he had miliary tuberculosis. I totally missed the diagnosis, despite all the tests, including liver and bone marrow biopsies before he died.

A decade later a case was presented at conference about a patient with a fever who went into multi-organ system failure and died. At the time of the conference I had zero recollection of the case from a decade earlier, but knew this was a case of miliary TB based on the data presented, although it was far from a textbook case. After the conference the presenter let me know that it had been my case, the one I had missed years ago.

I was ten years wiser in my medical career and more aware of the subtleties and variations of disease presentation. Experience has made me a somewhat better diagnostician. Or so I hope. Making the diagnosis of a common presentation of a common disease should be simple, but patients rarely read the textbooks and we are more likely to see an uncommon presentation of a common disease, a common presentation of an uncommon disease, and most dreaded, an uncommon presentation of an uncommon disease. (more…)

Posted in: Critical Thinking

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Influenza Eye Roll

Look!  A metaphor!

Look! A metaphor!

I don’t know the best metaphor. What comes around goes around. The more things change, the more they say the same. Sisyphus. Whack-A-Mole.

So what to do when the same old same old rears its head yet again? There are 2,545 posts on this blog, and I suppose I could just point to prior posts. But a blog entry that consists of links to prior posts would make the managing editor irritable. And we don’t want him irritable. Although those links are at the end of the post.

And WordPress is not a good format for reference material. I have trouble finding my own articles even when I know they exist and search for them using what I think are relevant terms.

It being the start of the flu season the same ole same ole nonsense is back about flu vaccines and influenza treatment. Influenza seasons vary, the nonsense does not. On the assumption that most of the readers of the post have no prior knowledge of what I have written on the topic, I thought I would tackle influenza yet again. (more…)

Posted in: Clinical Trials, Critical Thinking, Science and Medicine

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How not to debate a “pro-vaxer”

When people debating against vaccines win, children lose.

When people debating against vaccines win, children lose.

To say that the relationship that antivaccine activists have with science and fact is a tenuous, twisted one is a major understatement. Despite mountains of science that says otherwise, antivaccinationists still cling to the three core tenets of their faith, namely that (1) vaccines are ineffective (or at least nowhere near as effective as health officials claim; (2) vaccines are dangerous, causing autism, autoimmune disease, neurodevelopmental disorders, diabetes, sudden infant death syndrome, and a syndrome that is misdiagnosed as shaken baby syndrome; and, of course, (3) the Truth (capital-T, of course!) is being covered up by a nefarious combination of big pharma, the medical profession, and the government (in the US, primarily the Centers for Disease Control and Prevention, which works with pediatricians to produce the recommended schedule of vaccines). Because vaccine rejectors don’t have science on their side, they have to resort strategies common to science denialists like those who reject the scientific consensus about evolution or human-caused global climate change. These fallacious strategies include (but are not limited to) selective citation of evidence (i.e., cherry picking), misrepresentation and logical fallacies, impossible expectations about what science can deliver (e.g., vaccine denialists expecting 100% efficacy and 100% safety from vaccines or cancer quacks expecting 100% cure rates and no side effects from chemotherapy); fake experts (e.g., Andrew Wakefield); and, of course, conspiracy theories. Add to that appeals to personal freedom and “health choiceüber alles and painting any form of vaccine mandate as incipient totalitarianism, with those rejecting vaccines taking on the role of the Jews in Hitler’s Germany, and you have a pretty good idea of the sorts of arguments antivaccine activists resort to.

Not surprisingly, even the most diehard antivaccine advocate can get frustrated. After all, it must be very frustrating to have one’s posterior handed to one in arguments on the science of vaccines time and time again. Of course, for that purpose, like most science denialists, antivaccine activists have the Internet. In particular, they’ve taken full advantage of Facebook, and, more recently, Twitter. One such online gathering place is the public group known as Vaccine Resistance Movement (VRM). I encourage pro-science advocates to peruse this group, just to see that when I refer to people being anti-vaccine, there is no doubt that that is what they are. It was there that I found a rather telling document posted, for the benefit of antivaccine advocates everywhere.
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Posted in: Critical Thinking, Vaccines

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On “integrative medicine” and walking and chewing gum at the same time

Walk and chew gum at the same time

I didn’t think I’d be discussing Dr. David Katz again so soon. In fact, when Mark Crislip (who clearly hates me, given how often he sends me links to articles like this) sent me a link to Dr. Katz’s latest article, “Cleaning the House of Medicine“, published—where else?—in The Huffington Post, that home for “reputable” quack-friendly bloviation since 2005, when I first read the article, my first reaction was that Katz must surely be trolling us here at SBM. At first, I wasn’t going to respond to him again. However, Katz’s article represents a very common misconception about science-based medicine that is worth refuting. It is not my intention to be arguing back and forth with Dr. Katz every couple of weeks, but I did think it worth one more round. I think you’ll understand why by the end of this post.

First, however, a brief recap is in order for readers who might not have been following the discussion over the last month or so. It all started a couple of weeks ago, when Jann Bellamy, in response to a special issue of the American Journal of Preventative Medicine edited by Katz and dedicated to making the case for integrative medicine in preventive medicine training, quite correctly discussed how “integrative medicine” is always all about the “potential.” Indeed, after having spent considerable sums of federal grant money studying the “integration” of pseudoscience into medicine with respect to preventive care, the journal couldn’t come up with any concrete examples how integrative medicine adds anything (other than quackery) to medicine. Dr. Katz, who is well-known in the world of quackademic medicine for his infamous 2008 speech in which he asserted that physicians need to use a “more fluid concept of evidence” in evaluating treatments, particularly “complementary and alternative medicine” (CAM), responded with another HuffPo article entitled “Science and Medicine, Fools and Fanatics: The ‘Fluidity’ of Woo“. In lieu of reasonable, science-based arguments, Dr. Katz’ article was little more than a rant that consisted mainly of outrage that mere mortals lacking his awesome academic credentials had had the temerity to question his awesomeness and dedication to science coupled with an accusation that we are just too rigid and simplistic in our thinking to understand the subtle complexities of how different standards of evidence must be applied to complex patients. Steve Novella and I both responded that we understand just fine, explained how doctors do this all the time without using quackery like naturopathy and homeopathy (both of which Katz has advocated), and pointed out his argumentum ad ignorantiam with respect to energy medicine.

There’s where I thought it would end. Unfortunately, I was mistaken. On Friday, Katz launched another broadside at us, couched in the form of an argument that medicine must “clean its own house” before worrying about his quackademic medicine. It’s something I hear often enough that I thought it would be worth responding to, even if Dr. Katz was indeed trolling us.
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Posted in: Critical Thinking, Medical Academia, Quality Improvement, Surgical Procedures

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This Book Won’t Cure Your Cancer, But It Will Help You Think More Clearly About It

cancerGideon Burrows has an inoperable brain cancer that is slow growing but is inevitably going to kill him. He has written a remarkable book about his experience, This Book Won’t Cure Your Cancer. A professional wordsmith, he is able to describe his experience of illness so vividly that the reader enters into his life, feels what he feels, and shares his suspense about what the next scan or doctor’s visit will reveal. Along with him, we suffer through the panic and fear, the chaos, the agonies of delays and uncertainty, the unpleasant hospital environment, and specialists with poor bedside manners. We follow him through difficult decisions about how to share the bad news with friends, relatives, and his young children; and we understand why this engenders guilt feelings. The story is as engaging as a detective story; we can hardly wait to see what the next scan will show and how the story of his illness will play out. It puts a human face on the cancer experience, and it would be valuable for that alone, but it is much more. The gradually unfolding episodes of his personal story are interwoven with what amounts to a primer on how to think critically about science-based medicine vs. alternative treatments. I can’t recommend this book highly enough.
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Posted in: Book & movie reviews, Cancer, Critical Thinking

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Authority versus science on integrative medicine

Should we respect David Katz's authority?

Should we respect David Katz’s authority?

David Katz doesn’t much like us here at Science-Based Medicine. In fairness, I can’t say that I much blame him. We have been very critical of his writings and talks over the years, dating back as far as Steve Novella’s deconstruction of one of Dr. Katz’s more infamous statements about using a “more fluid concept of evidence” to Kimball Atwood’s characterization of his tortured logic to my pointing out that his arguments frequently boil down to a false dichotomy of either abandoning science or abandoning patients.

Last week, Jann Bellamy did her usual great job discussing an unfortunate special supplement of the American Journal of Preventative Medicine (AJPM) entitled Integrative Medicine in Preventive Medicine Education. This supplement included articles summarizing the results of project called IMPriME (Integrative Medicine in Preventive Medicine Education), funded by the Health Resources and Services Administration (HRSA), to advance the inclusion of “integrative medicine” in Preventive Medicine residency programs. Not surprisingly, this project was led by Dr. Katz. Jann used this special issue as a jumping off point to show, quite correctly, how, when it comes to so-called “integrative medicine,” it is always about the “potential,” which has always been elusive and has never been realized. Unfortunately, the elusiveness of the amazing potential attributed to “integrative medicine” (formerly referred to as “complementary and alternative medicine” or “CAM”) has done almost nothing to dampen the ardor of its cheerleaders for “integrating” as much woo as they can into medicine, which is why a major journal would allow someone like David Katz to edit a special issue dedicated to articles discussing IMPriME’s findings.

Thanks to Jann’s post, it appears that Dr. Katz is most displeased with us again here at SBM. To express his displeasure, he has rattled off a little rant over at his usual non-academic hangout and quack-friendly Internet outlet, The Huffington Post. There, he castigates us with a post entitled Science and Medicine, Fools and Fanatics: The ‘Fluidity’ of Woo. Yes, right off the bat, it’s the same old strategy, to paint advocates of “integrative medicine” as the “reasonable” ones while those of us who object to integrating prescientific quackery into medicine are clearly the “fanatics” (or, if you prefer, the fools). In it, as usual, Dr. Katz lays down some real howlers in defense of his integration of woo with medicine.
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Posted in: Basic Science, Critical Thinking, Medical Academia

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October is National Chiropractic Health Month!

nchm-logo-for-web
October is National Chiropractic Health Month (NCHM) and chiropractors can’t resist the opportunity to overstate, obfuscate, and prevaricate in celebration.

They do this in the face of some unfortunate (for them) statistics revealed by a recent Gallup Poll. The Poll was paid for by Palmer College of Chiropractic as part of an effort to increase the chiropractic share of the health care pie. (There is also a secondary analysis of the poll in the Journal of Manipulative and Physiological Therapeutics.) We’ll get to those stats in a few minutes.

But first, in celebration of NCHM, the American Chiropractic Association (ACA) has produced a set of six graphics chiropractors can download and display. Four of them fudge on the facts. Let’s take a look at these graphics, compare them to the evidence cited in support of their claims, and see where the ACA went astray. (The ACA also hosted a twitter chat yesterday with the hashtag #PainFreeNation.)

chiro-infographic-spinal-manip-low-back-pain

The study cited as evidence for this graphic actually compared both manual thrust manipulation (MTM) and mechanical-assisted manipulation (MAM) to each other as well as manipulation versus usual medical care (UMC). Although MAM, such as the Activator Method, is the second most common manipulation technique used by American chiropractors, is increasing in popularity among them, and is touted to be a safe and effective alternative to MTM, this study found that MTM is more effective (at 4 weeks) than MAM and that MAM had no advantage over UMC. But you don’t see that in this graphic.

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Posted in: Chiropractic, Clinical Trials, Critical Thinking

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“Aborted fetal tissue” and vaccines: Combining pseudoscience and religion to demonize vaccines

Yes, there are antivaccinationists who actually believe this.

Yes, there are antivaccinationists who actually believe this.

As hard as it is to believe after seven and a half years of existence and nearly 2,400 posts on SBM, every so often, something reminds me that we here at SBM haven’t discussed a topic that should be discussed. So it was a couple of weeks ago, when I saw a familiar name in a news story that wasn’t about vaccines. You might recall a news story last month when a shadowy group with ties to radical antiabortion groups, the Center for Medical Progress, led by a man named David Daleiden, ran a highly questionable “sting” operation (complete with fake IDs) to “prove” that Planned Parenthood was selling aborted fetuses for medical research.

While reading news stories about Daleiden and CMP, I came across a familiar name, a name that many of us who discuss antivaccine misinformation are familiar with. I’m referring to Theresa Deisher, founder of the Sound Choice Pharmaceutical Institute. It turns out that Deisher helped to prepare Daleiden for his role as a biomedical representative that he assumed in order to deceive representatives of Planned Parenthood. She taught him how to talk the talk and walk the walk, so to speak, so that he was convincing as a representative of a biomedical research firm.

I can hear you asking: So what? What do Daleiden and CMP have to do with vaccines? It’s not CMP per se, but Deisher who is relevant. The reason that Deisher is so relevant to Science-Based Medicine (SBM) is because she is one of the foremost promoters of a particularly pernicious form of antivaccine misinformation that tries desperately to create a religious basis to oppose vaccines with antivaccine activism. It is a form of misinformation designed to deceive those who believe abortion is a moral wrong into thinking that vaccines, too, are a moral wrong because some of the viruses used to make specific vaccines are grown during the manufacturing process in cell lines derived from human fetuses decades ago. But Deisher goes one huge step beyond just guilt by association for vaccines. She is, as the news story cited above notes, the foremost promoter of a related and equally pernicious form of antivaccine information that claims that DNA from the fetal cell lines used to grow vaccine strains of viruses is a cause of autism. The truly depressing thing about Deisher is that she is, in fact, a real scientist (or at least was).

In any event, it occurred to me that, although I’ve mentioned Deisher briefly before in the context of the Disneyland measles outbreak, I’ve never deconstructed her antivaccine misinformation in detail here. Yet, her work is often cited by antivaccine activists to persuade those whose religion tells them abortion is morally wrong that they shouldn’t vaccinate their children by adding to the false claim that somehow “fetal parts” are used in the making of vaccines the even more false claim that fetal DNA somehow gets into the brain, recombines with the DNA in neurons, and causes autism. She’s also just released what appears to be a new paper claiming to show how fetal DNA causes autism. The confluence of her name coming up in stories about CMP and Planned Parenthood and her release of this new “paper” makes this a perfect time to write about Deisher.
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Posted in: Basic Science, Critical Thinking, Religion, Vaccines

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Answering Cancer Quackery: The Sophisticated Approach to True Believers

 You can lead a true believer to facts, but can you make him think?

You can lead a true believer to facts, but can you make him think?

I got an e-mail with a link to a video featuring “Dr.” Leonard Coldwell, a naturopath who has been characterized on RationalWiki as a scammer and all-round mountebank. Here are just a few examples of his claims in that video:

  • Every cancer can be cured in 2-16 weeks.
  • The second you are alkaline, the cancer already stops. A pH of 7.36 is ideal; 7.5 is best during the healing phase. [We are all alkaline. Normal pH is 7.35-7.45.]
  • IV vitamin C makes tumors disappear in a couple of days.
  • Very often table salt is 1/3 glass, 1/3 sand, and 1/3 salt. The glass and sand scratch the lining of the arteries, they bleed, and cholesterol is deposited there to stop the bleeding.
  • Patients in burn units get 20-25 hard-boiled eggs a day because only cholesterol can rebuild healthy cells; 87% of a cell is built on cholesterol.
  • Medical doctors have the shortest lifespan: 56. [Actually they live longer than average.]

My correspondent recognized that this video was dangerous charlatanism that could lead to harm for vulnerable patients. He called it a “train wreck, with fantasy piled upon idiocy.” His question was about the best way to convince someone that it was insane. He said, “If you could rely on someone to follow and understand basic information about the relevant claims, it would be a gimme. But to the casual disinterested observer, who can interpret the whole video as ‘Well, he just wants people to eat right,’ pointing out the individual bits of lunacy just looks like so much negativity.”

He asked, “How do I best represent what’s happening to someone who is either a) emotionally invested in this and/or b) casually approving of it? … I just want to be patient, not shout anyone down, not make anyone defensive, and then win. Very surprised I don’t already know how. But I feel like I don’t. What is the psychologically sophisticated approach to this?” (more…)

Posted in: Book & movie reviews, Critical Thinking, Religion

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Don’t just stand there, do nothing! The difference between science-based medicine and quackery

Tree of Life - the first-known sketch by Charles Darwin of an evolutionary tree describing the relationships among groups of organisms (Cambridge University Library).

Tree of Life – the first-known sketch by Charles Darwin of an evolutionary tree describing the relationships among groups of organisms (Cambridge University Library).

The Merriam-Webster Dictionary defines science as:

Knowledge about or study of the natural world based on facts learned through experiments and observation.

And:

Knowledge as distinguished from ignorance or misunderstanding.

While this should distinguish science from pseudoscience, those who practice the latter often lay claim to the same definition. But one of the major differences between science and pseudoscience is that science advances through constant rejection and revision of prior models and hypotheses as new evidence is produced; it evolves. This is the antithesis of pseudoscience. At the heart of pseudoscience-based medicine (PBM) is dogma and belief. It clings to its preconceptions and never changes in order to improve. It thrives on the intransigence of its belief system, and rejects threats to its dogma. Despite the constant claims by peddlers of pseudoscience that SBM practitioners are closed-minded, we know that, in fact, PBM is the ultimate in closed-minded belief. Of course, those of us who claim to practice SBM aren’t always quick to adopt new evidence. We sometimes continue practices that may once have been the standard of care but are no longer supported by the best available evidence, or perhaps may even be contradicted by the latest evidence. Often this is a byproduct of habituated practice and a failure to keep current with the literature. While this is certainly a failure of modern medicine, it is not an inevitable outcome. It is not emblematic of the practice of medicine, as it is with PBM. When medicine is science-based, it strives for continual improvement based on modifications around emerging evidence. (more…)

Posted in: Critical Thinking, Medical Ethics, Public Health, Science and Medicine

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