Critical Thinking

Archive for Critical Thinking

In which we are accused of “polarization-based medicine”


A little over a month ago, I wrote about how proponents of “complementary and alternative medicine” (CAM), now more frequently called “integrative medicine,” go to great lengths to claim nonpharmacological treatments for, well, just about anything as somehow being CAM or “integrative.” The example I used was a systematic review article published by several of the bigwigs at that government font of pseudoscience, the National Center for Complementary and Integrative Health (NCCIH) about CAM approaches for the management of chronic pain. You can read my whole post for yourself if you want the details (and read Edzard Ernst and Steve Novella for more), but the CliffsNotes version consists of two main points. First, the review didn’t really show that any CAM approach worked, given how the authors included so many studies with no placebo or sham control and didn’t systematically assess the quality of the studies. Second, this study is the best publicized example of how NCCIH, looking for a reason to justify itself, has latched on to the opioid addiction crisis in this country and gone “all in” with CAM for chronic pain. Of course, the problem is that none of the real “alternative” treatments show any convincing evidence of efficacy; so NCCIH has to claim exercise (in the form of yoga and Tai Chi, for instance) and various other modalities that aren’t really “alternative” as being part of CAM. True, the authors did try to claim that acupuncture works for back pain and osteoarthritis of the knee, but the flaw of including mostly studies with no placebo/sham control completely undermined that claim. Basically, taken in its entirety, the NCCIH’s systematic review failed to find convincing evidence that any CAM therapy really works for chronic pain.

So I wrote my post, noting also how this review article and its framing of CAM as equivalent to any nonpharmacologic treatment were clearly in line with the last two NCCIH strategic plans, perused the comments our readers left, and pretty much forgot about the study, because fortunately, it didn’t seem to get much traction. (Releasing it right before the Labor Day weekend probably didn’t help NCCIH much.) However, there is one person who did not forget, and that person is John Weeks. Last week, he published a response to the criticisms of the NCCIH review in the Journal of Alternative and Complementary Medicine (JACM) entitled “Polarization-Based Medicine: Protests Against the Mayo-NCCIH Pain Guidance Evoke the Bigotry of the Political Season.”

As they say, it’s on.

Posted in: Clinical Trials, Critical Thinking, Medical Academia, Politics and Regulation

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Building a Case for CAM

[Editor’s note: Mark Crislip is taking a well deserved vacation from blogging, and James Thomas has kindly agreed to provide another guest post to fill the gaping need left in all of your lives. Enjoy!]

Building a case for complementary and alternative medicine. This shouldn't be hard!

Building a case for complementary and alternative medicine. This shouldn’t be hard!

According to the Orwellian-named National Center for Complementary and Integrative Health, roughly 33% of adults aged 18-44 and about 37% aged 45-64 use some form of CAM. More disturbing is that 12% of children aged 4-17 used some form of CAM in the last 12 months. If there is good news, it is that the NCCIH takes a broad view of “complementary health approaches” including acupuncture, Ayurveda, biofeedback, chelation therapy, chiropractic care, energy healing therapy, special diets (including vegetarian and vegan, macrobiotic, Atkins, Pritikin, and Ornish), folk medicine or traditional healers, guided imagery, homeopathic treatment, hypnosis, naturopathy, non-vitamin, non-mineral dietary supplements, massage, meditation, progressive relaxation, qi gong, tai chi, and yoga. In fact these approaches range from the wacky (energy healing therapy, homeopathy) to the mainstream (massage, yoga) with nothing alternative about them. With more than 60 million Americans using some form of CAM, it is fair to ask if we can build a case for truly integrating CAM into mainstream medical practice.

So who are these people using CAM and just what are they using it for? CAM users can be found in almost every demographic but the largest cohort is white, female, and fairly well educated. A good deal of CAM is used for common and often vague conditions with back pain being the most commonly cited. But it is also used by cancer patients, for cardiovascular disease, and even for Alzheimer’s disease. The problem is that none of the CAM approaches are useful for any of these conditions; strike that, none of the CAM approaches are useful for anything at all much beyond placebo.

I’m going to keep this essay down to a more reasonable length than my earlier offerings (pauses here for the applause to fade) so I’m not going to talk much about most CAM “modalities.” Reiki is deconstructed here and here, or for those who just want a Crislipian good time, here. Homeopathy is eviscerated here. For the deeper dive go here, or for the full monte, here. If after that you still have questions about homeopathy you should probably get a hobby.

But wait, there’s more!

Chiropractic, and acupuncture, and hypnosis, and chelation, and, and…go to the masthead and enter the CAM of your choice in the box with the little magnifying glass. If some charlatan has offered it as a medical treatment, this is your gateway to good information about it. But (and that ‘but’ was your spoiler alert), none of it has much impact on any measurable medical condition. CAM does not shrink tumors, CAM does not dilate bronchi, CAM does not strip pounds of icky toxins out of your colon. Those claims and most others are easily dismissed by anyone with basic reasoning skills and the URL for Pubmed (here it is:

There are however, two arguments in favor of CAM that deserve a bit more careful consideration: electro-acupuncture for pain relief through the mechanism of stimulating endorphin release, and the more general argument that many patients have needs unmet by the medical mainstream, often psycho-social needs that do not have an ICD-10 (a type of diagnostic code) and for which no treatment infrastructure exists within the mainstream health care delivery system. These are the cases I’ll try to build today. (more…)

Posted in: Critical Thinking, Science and Medicine

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Quackery: The 20 Million Dollar Duck

The publisher recently sent me a review copy of Quackery: The 20 Million Dollar Duck, by Tony Robertson. My first thought was “Do we really need another book on this subject? Don’t I know all this stuff already?” I was very pleasantly surprised. Robertson has ferreted out an impressive array of facts and details that I wasn’t aware of; and yes, we need as many good books on the subject as we can get. Each author has a somewhat different approach that may appeal to a different audience. Robertson’s book is a worthy addition to the canon. He is a retired gynecologist who practiced, taught, and still lives in Zimbabwe. He is a critical thinker who understands and promotes science-based medicine, and he brings a unique perspective, especially on subjects related to his specialty. The book is not just about charlatans, it’s about non-science-based practices wherever they are found, including in mainstream medicine and in Robertson’s own field of obstetrics and gynecology.

I expected to like the book after I read the Dedication “To those who appreciate the truth fairy rather than the toothed one” and the Acknowledgements: “To my teachers and mentors who encouraged me to think, always to question and only to accept where there is good evidence.” That could serve as a motto for all skeptics, scientists, and critical thinkers to live by: Think, question, and only accept where there is good evidence. (more…)

Posted in: Book & movie reviews, Critical Thinking, Obstetrics & gynecology

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Statistics Done Wrong, And How To Do Better

Statistics done wrong Alex Reinhart
Statistics is hard, often counterintuitive, and burdened with esoteric mathematical equations. Statistics classes can be boring and demanding; students might be tempted to call it “Sadistics.” Good statistics are essential to good research; unfortunately many scientists and even some statisticians are doing statistics wrong. Statistician Alex Reinhart has written a helpful book, Statistics Done Wrong: The Woefully Complete Guide, that every researcher and everyone who reads research would benefit from reading. The book contains a few graphs but is blissfully equation-free. It doesn’t teach how to calculate anything; it explains blunders in recent research and how to avoid them.

Inadequate education and self-deception

Most of us have little or no formal education in statistics and have picked up some knowledge in a haphazard fashion as we went along. Reinhart offers some discouraging facts. He says a doctor who takes one introductory statistics course would only be able to understand about a fifth of the articles in The New England Journal of Medicine. On a test of statistical methods commonly used in medicine, medical residents averaged less than 50% correct, medical school faculty averaged less than 75% correct, and even the experts who designed the study goofed: one question offered only a choice of four incorrect definitions.

There are plenty of examples of people deliberately lying with statistics, but that’s not what this book is about. It is about researchers who have fooled themselves by making errors they didn’t realize they were making. He cites Hanlon’s razor: “never attribute to malice that which is adequately explained by incompetence.” He says even conclusions based on properly done statistics can’t always be trusted, because it is trivially easy to “torture the data until it confesses.” (more…)

Posted in: Book & movie reviews, Critical Thinking

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About Herbs: an app to avoid

Pictured: A better source of health information than "About Herbs".

Pictured: A better source of health information than “About Herbs”.

Medicine has an intellectual hierarchy. Supposedly the best and the brightest are in the academic medical centers and are the thought leaders in their field.

Those of us lower in the hierarchy are well aware of some of the warts present on our betters, but I would expect those at the top would adhere to the highest intellectual and ethical standards. People being, well, people, expecting exceptional standards is admittedly an unrealistic expectation.

It would appear that many academic centers are doing their best to avoid meeting my expectations, attempting to abandon all standards.

I mentioned over at SfSBM that Dana-Farber is spending 2 million dollars on a renovation to, in part, offer the unmitigated steer manure that is reiki and reflexology to their cancer patients. Yes. Reiki. Reflexology.

Those are not fracking earthquakes in Kentucky, those tremors are the result of the tremendous kinetic energy of Flexner spinning in his grave as his life’s work becomes a farce.

Dana-Farber is just one of many academic medical centers who are putting their imprimatur on nonsense.

Memorial Sloan Kettering Cancer Integrative has released “About Herbs”, an iPad/iPhone guide to Botanicals, Supplements, Complementary Therapies and More. Spoiler alert: the ‘More’ does not include critical thinking. This guide is not anywhere as ludicrous as offering reeky, sorry, reiki, but at times it comes close. (more…)

Posted in: Acupuncture, Commentary, Critical Thinking, Herbs & Supplements, Homeopathy, Traditional Chinese Medicine

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Use of Dental Appliances in the Management of Tourette Syndrome

Editor’s note: This Science Based Medicine blog post is another collaborative effort between Grant Ritchey and Clay Jones. Not only have they previously co-authored an SBM post on fluoride, their partnership has recently expanded into other areas of science journalism. Since the departure of Dr. Jason Luchtefeld as co-host of The Prism Podcast, Clay has joined Grant as the new co-host. To this end, Clay and Grant have added a Science Based Medicine segment to each podcast episode, in which recent SBM blog posts are reviewed and discussed with the authors themselves. Check them out on iTunes or your favorite podcatcher.

"We'll remove that headgear when your tics improve."

“We’ll remove that headgear when your tics improve.”

One of our primary goals is to promote the concept of scientific skepticism and the importance of prior plausibility when interpreting new research. On the pages of this website, and in extracurricular activities like our various podcasts and personal blogs, we often call upon these two load-bearing pillars of science-based medicine when investigating implausible and unproven claims championed by well-meaning true believers and outright charlatans. What our collective experience has revealed time and time again is that both will often hope that a gullible public will put their trust in a warped version of science, while relying on emotional responses to anecdotes and testimonials.

In our post today, we will walk readers through our investigation of thus far unproven claims involving the treatment of a complex neurological disorder, Tourette syndrome (TS), with a fitted dental appliance aimed at improving the alignment of a patient’s jaw. From the perspective of a dentist (Grant) and a pediatrician (Clay), there aren’t any obvious connections between the jaw and this childhood-onset neuropsychiatric disorder, but proponents believe that there is one and that these appliances can significantly reduce the severity of symptoms. Although impossible to enter into an investigation such as this completely free of emotion or bias, we truly attempted to keep an open mind throughout the process.

First up, a disclaimer:

Clay was diagnosed with Tourette syndrome when he was 7 years old. As both a pediatrician who has now cared for a number of patients with TS and someone who has personally experienced many of the negative physical and social sequelae associated with the condition, this is a topic that Clay takes rather personally. Although his symptoms are now on the milder end of the severity spectrum, and are far from debilitating, they do often serve as a source of frustration in his day-to-day life. The thought of children with Tourette syndrome being taken advantage makes him angrier than that time somebody switched out his regular coffee for Colombian decaffeinated crystals.

Without hesitation, we would love for there to be another effective treatment option for Tourette syndrome in our armamentarium, especially one that would be essentially risk free and relatively inexpensive. Again, as scientific skeptics we are open to new evidence as it emerges. But before we get to the claim and the research being used to back it up, we will give a primer on the scientific consensus on TS so that readers can better assess for themselves the prior plausibility of this proposed treatment.

Posted in: Critical Thinking, Dentistry, Medical devices

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Fooling Myself

They may have different packages, but these products are all the same inside.

Nothing says opportunistic like selling water for pain control.

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

Richard Feynman

I like to think of myself as a rational person, but I’ve been fooled by my own experience again and again. I’ve made bad decisions and wasted time and money believing what I was seeing, instead of being objective and looking at the evidence. One of my most memorable lessons has come over the past 14 years with my Labrador Retriever, Casey.

First the personal

We acquired Casey as a puppy, and she was less than a year old when she started limping. Investigations confirmed dysplasia, a genetic condition that leads to degenerative joints, arthritis, and pain. We were devastated. After considering the few treatment options that existed, we decided to skip surgery and treat it conservatively. I had no desire to start her on a lifetime of anti-inflammatory drugs, being very familiar with their side effect profile. I was familiar with a supplement used widely in humans that had some weak but somewhat promising evidence: We started giving her glucosamine and chondroitin supplements regularly. And we watched and waited.

It took some time, but Casey did appear to improve. We were thrilled. Life went on, and other than the occasional rough play session, Casey’s limping was mild, and she thrived. We continued the supplements, confident that we were doing good. But eventually I started paying attention to the emerging evidence on glucosamine and chondroitin. Once touted as a panacea for arthritis and joint pain, there had finally been some high-quality trials conducted – and the results were disappointing. Even this blog covered the issue, and contributors like Harriet were skeptical of glucosamine. Its supposed mechanism of action really wasn’t even that plausible. I started to wonder if the supplements were really doing anything for my dog’s pain. Eventually I decided on a trial – so I stopped the supplements about seven years after I started them. Neither my wife nor I could notice any difference at all in her mobility. Nor did the veterinarian. We’d been fooling ourselves, spending hundreds of dollars in the process. (more…)

Posted in: Critical Thinking, Herbs & Supplements, Science and Medicine

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“Integrative” medicine versus “alternative” medicine

“Integrative” medicine versus “alternative” medicine

I’ve written a lot about the language issue with respect to alternative medicine. As I like to put it (at least in shortened form), first there was quackery. Quacks did not like that name at all, and thus was born alternative medicine. And the quacks did think it good—for a while. There was a problem, however. “Alternative” medicine implied (correctly, of course) that what was being discussed was not real medicine, and the quacks could not abide that. Thus was born “complementary and alternative medicine” (CAM).

And the quacks thought this very good indeed.

Unfortunately, it was not long before the problem with the term CAM became apparent. It had the word “complementary” in it. The implication of that word, of course, is that what they were doing was still somehow not real medicine. It was complementary to real medicine, the icing on the cake, if you will. Real medicine could do without it, and having that implication in the very name that their evolving specialty had taken on was offensive to the quacks.

So they changed it.

Posted in: Basic Science, Critical Thinking, Science and the Media

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Chiropractic- Ignoring the Precautionary Principle Since 1895

My reaction to reading the paper discussed herein, were I a handsome Spaniard.

My reaction to reading the paper discussed herein, were I a handsome Spaniard.

Bleh. I turned from a short trip to the city of angles with a bad man cold that just isn’t going away. Those who do primary care all tell me that whatever is going around lasts 2-3 weeks. Great. I am not sick enough to get out of work but I am not well enough to have any enthusiasm to do anything. I look at the key board and sigh. I just want to binge watch something mindless.

I know Harriet covered “Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation” last week. But it is one thing to read the evaluation of a paper and quite another to evaluate a paper on your own. It is the latter process where you, and by you I mean me, actually learn something. I write mostly for my edification, not yours. Sorry. It is all about me. I will likely read Harriet’s post this weekend.

The issue at hand is whether chiropractic manipulation can cause a stroke. (more…)

Posted in: Chiropractic, Clinical Trials, Critical Thinking

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Functional medicine: The ultimate misnomer in the world of integrative medicine

Functional Medicine practitioners like to make patients think that this diagram actually means something.

Functional Medicine practitioners like to make patients think that this diagram actually means something.

We at Science-Based Medicine often describe “integrative medicine” as integrating quackery with medicine (at least, I often do), because that’s what it in essence does. The reason, as I’ve described time and time again, is to put that quackery on equal footing (or at least apparently equal footing) with science- and evidence-based medicine, a goal that is close to being achieved. Originally known as quackery, the modalities now being “integrated” with medicine then became “complementary and alternative medicine” (CAM), a term that is still often used. But that wasn’t enough. The word “complementary” implies a subordinate position, in which the CAM is not the “real” medicine, the necessary medicine, but is just there as “icing on the cake.” The term “integrative medicine” eliminates that problem and facilitates a narrative in which integrative medicine is the “best of both worlds” (from the perspective of CAM practitioners and advocates). Integrative medicine has become a brand, a marketing term, disguised as a bogus specialty.

Of course, it’s fairly easy to identify much of the quackery that CAM practitioners and woo-friendly physicians have “integrated” itself into integrative medicine. A lot of it is based on prescientific ideas of how the human body and disease work (e.g., traditional Chinese medicine, especially acupuncture, for instance, which is based on a belief system that very much resembles the four humors in ancient “Western” or European medicine); on nonexistent body structures or functions (e.g., chiropractic and subluxations, reflexology and a link between areas on the palms of the hands and soles of the feet that “map” to organs; craniosacral therapy and “craniosacral rhythms”); or vitalism (e.g., homeopathy, “energy medicine,” such as reiki, therapeutic touch, and the like). Often there are completely pseudoscientific ideas whose quackiness is easy to explain to an educated layperson, like homeopathy.

Posted in: Critical Thinking, Diagnostic tests & procedures, Herbs & Supplements

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