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What is Science?

Consider these statements:

…there is an evidence base for biofield therapies. (citing the Cochrane Review of Touch Therapies)

The larger issue is what constitutes “pseudoscience” and what information is worthy of dissemination to the public. Should the data from our well conducted, rigorous, randomized controlled trial [of ‘biofield healing’] be dismissed because the mechanisms are unknown or because some scientists do not believe in the specific therapy?…Premature rejection of findings from rigorous randomized controlled trials are as big a threat to science as the continuation of falsehoods based on belief. Thus, as clinicians and scientists, our highest duty to patients should be to investigate promising solutions with high benefit/risk ratios, not to act as gatekeepers of information based on personal opinion.

–Jain et al, quoted here

Touch therapies may have a modest effect in pain relief. More studies on HT and Reiki in relieving pain are needed. More studies including children are also required to evaluate the effect of touch on children.

Touch Therapies are so-called as it is believed that the practitioners have touched the clients’ energy field.

It is believed this effect occurs by exerting energy to restore, energize, and balance the energy field disturbances using hands-on or hands-off techniques (Eden 1993). The underlying concept is that sickness and disease arise from imbalances in the vital energy field. However, the existence of the energy field of the human body has not been proven scientifically and thus the effect of such therapies, which are believed to exert an effect on one’s energy field, is controversial and lies in doubt.

—Cochrane Review of Touch Therapies, quoted here

 …

Science is advanced by an open mind that seeks knowledge, while acknowledging its current limits. Science does not make assertions about what cannot be true, simply because evidence that it is true has not yet been generated. Science does not mistake absence of evidence for evidence of absence. Science itself is fluid.

—David Katz

When people became interested in alternative medicines, they asked me to help out at Harvard Medical School. I realized that in order to survive there, one had to become a scientist. So I became a scientist.

—Ted Kaptchuk, quoted here.

 …It seems that the decision concerning acceptance of evidence (either in medicine or religion) ultimately reflects the beliefs of the person that exist before all arguments and observation.

 —Ted Kaptchuk, quoted here.

Together they betray a misunderstanding of science that is common not only to “CAM” apologists, but to many academic medical researchers. Let me explain. (more…)

Posted in: Basic Science, Book & movie reviews, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Homeopathy, Medical Academia, Science and Medicine

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Adventures in defending science-based medicine in cancer journals: Energy chelation

My co-bloggers and I have spent considerable time and effort over the last four years writing posts for this blog (and I for my not-so-super-secret other blog) bemoaning the infiltration of quackademic medicine into what once were bastions of evidence- and science-based medicine. We’ve discussed at considerable length reasons for why this steady infiltration of pseudoscience into medical academia has been occurring. Among other potential explanations, these reasons range from the ascendence of postmodernism in areas where it really doesn’t belong; to a change in our medical culture to a more “consumer”-oriented, “keep the customer satisfied”-sort of model in which patients are often referred to as “clients” or “customers”; to the corrosive influences of moneyed groups (such as the Bravewell Collaborative) and government agencies (such as the National Center for Complementary and Alternative medicine, a.k.a. NCCAM); to the equally corrosive influences of powerful woo-friendly legislators who use their position and influence to create such agencies (such as Senator Tom Harkin and Representative Dan Burton) and otherwise champion “complementary and alternative medicine” (CAM) and “integrative medicine” because they are true believers in quackery; to cynical legislators, like Senator Orrin Hatch, who champions such government programs supporting pseudoscience because he represents a state that is home to the largest concentration of supplement manufacturers in the United States and is consequently a master at bringing any initiative to regulate the supplement industry more tightly to a screeching halt.

As a result of our efforts and the need for a counterweight to the quackery that has infiltrated so much of academia, SBM has become fairly prominent in the medical blogosphere. Our traffic is good, and we have a number of “thought leaders” who regularly read what we write. We’ve even caught the attention of Dr. Josephine Briggs, director of NCCAM, and our founder Steve Novella was even invited to appear on The Dr. Oz Show for “balance.” All of this is something that we are justly proud of. On the other hand, I can’t help but keep things in perspective. While our traffic as a blog is quite respectable and we have become prominent in the skeptical and medical blogosphere and even, to some extent, in academia—we’re particularly gratified at the number of medical students who are regular readers—compared to the forces arrayed against SBM in academia and the media, we have to face facts: We are truly a tiny voice in the wilderness. For instance, we average around 9,000 to 16,000 visits a day. Compare that traffic to the many millions who used to watch Oprah Winfrey and still watch her protégé Dr. Oz or to health media and product empires of people like Andrew Weil and Deepak Chopra, and you get the idea.

All of this is why I started looking for opportunities to respond more directly to incursions of pseudoscience into medical academia. Occasional SBM contributor Peter Lipson provided me with just such an opportunity last summer when he sent me a link to a brain-meltingly bad study about the use of CAM in cancer that shows just how bad a study can be and still be published in what I used to consider a reasonably good cancer journal. I say “used to consider,” because the fact that this journal accepted a study this ludicrous indicates to me that its peer review is so broken that I now wonder about what else I’ve read in that journal that I should now discount as being too unreliable to take seriously. Maybe everything. I don’t know. What I do know is that seldom have I seen such a bad study in such a good cancer journal. Studies like the one about Tai Chi in fibromyalgia or placebo acupuncture applied to asthma don’t even come close.

Soon after this study appeared online ahead of print, James Coyne contacted me and asked me if I wanted to be co-author on a letter to the editor of the journal. Honored by Dr. Coyne’s request, I immediately said yes (of course), and together with Dr. Christoffer Johansen at the Survivorship Unit of the Danish Cancer Society, we submitted our letter to the editor. To my surprise, given the utter failure of past efforts to publish letters to the editor about studies of this sort, our letter was accepted for publication. Last week, the study in question saw print, and our letter was published online ahead of print, along with the response of the authors. All are instructive and, to me, show just what we are up against in trying to prevent pseudoscience from creeping into academia.
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Posted in: Cancer, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Medical Academia

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Survey says, “Hop on the bandwagon of ‘integrative medicine’!”

A Brief Clinical Vignette

In researching this post, I found an article published nearly two years ago in The Hospitalist entitled Growth Spurt: Complementary and alternative medicine use doubles, which began with this anecdote:

Despite intravenous medication, a young boy in status epilepticus had the pediatric ICU team at the University of Wisconsin School of Medicine and Public Health in Madison stumped. The team called for a consult with the Integrative Medicine Program, which works with licensed acupuncturists and has been affiliated with the department of family medicine since 2001. Acupuncture’s efficacy in this setting has not been validated, but it has been shown to ease chemotherapy-induced nausea and vomiting, as well as radiation-induced xerostomia.

Following several treatments by a licensed acupuncturist and continued conventional care, the boy’s seizures subsided and he was transitioned to the medical floor. Did the acupuncture contribute to bringing the seizures under control? “I can’t say that it was the acupuncture — it was probably a function of all the therapies working together,” says David P. Rakel, MD, assistant professor and director of UW’s Integrative Medicine Program.

The UW case illustrates both current trends and the constant conundrum that surrounds hospital-based complementary medicine: Complementary and alternative medicine’s use is increasing in some U.S. hospitals, yet the existing research evidence for the efficacy of its multiple modalities is decidedly mixed.

My jaw dropped in horror when I read this story. Acupuncture for status epilepticus? There’s no evidence that it works and no scientific plausibility suggesting that it might work. And what does the questionable research suggesting that acupuncture might ease chemotherapy-induced nausea and vomiting or radiation-induced xerostomia (which, if you look more closely at the studies, it almost certainly does not, but that’s a post for another time) have to do with this case, anyway? Nothing. Worse, Dr. Rakel fell for the classic post hoc ergo propter hoc fallacy; i.e., despite his disclaimer, he appears to be implying that, because the child recovered, acupuncture must have contributed to his recovery. He also repeats the classic fallacy that I’ve written about time and time again in the context of cancer therapy, namely that if a patient is using quackery as well as science-based medicine, then either it was the quackery that cured him or the quackery somehow made the conventional medical care work better.

I expect better from an academic medical center like the University of Wisconsin. Unfortunately, increasingly I’m not getting it. Quackademic medicine is infiltrating such medical centers like kudzu.
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Posted in: Faith Healing & Spirituality, Medical Academia, Science and the Media

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Train Therapy

Summertime and the living is busy.  Finally we have sun in the Northwest.  While the rest of the country has been melting in heat, this year we have rarely cracked 85.  Global heating has avoided Oregon this year, and I will need some green tomato recipes.  Good weather, work is busy, and it is the last two weeks with my eldest before he is off to Syracuse, so there is little time for writing, so a brief entry this week.

I always wince at the way anything can be called ‘therapy.’ We have music therapy and garden therapy and pet therapy and art therapy.  I do not deny that it is beneficial for people to participate in those activities while in the hospital, although I am never happy to see disease vectors, er, animals in a hospital.   Dinner should be food therapy, reading should be book therapy, and using the internet should be computer therapy.  I guess it is like calling something ‘medical’ grade, and you can bill more for it.

Some ‘therapies’ are a wee bit more odd.  Indonesians are using railroad therapy.  People lie down on electric railroad tracks because “the electricity current from the track could cure various diseases.”  To date no one has been either electrocuted or squashed, but I suppose it is only a matter of time.

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Posted in: Energy Medicine, Faith Healing & Spirituality, Science and the Media

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The Power of Faith and Prayer?

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.

Intercessory Prayer

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.

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Posted in: Faith Healing & Spirituality

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Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine

Background

This post concerns the recent article in the New England Journal of Medicine (NEJM) titled “Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma.” It was ably reviewed by Dr. Gorski on Monday, so I will merely summarize its findings: of the three interventions used—inhaled albuterol (a bronchodilator), a placebo inhaler designed to mimic albuterol, or ‘sham acupuncture’—only albuterol resulted in a clinically important improvement of bronchial airflow; for that outcome the two sham treatments were equivalent to “no intervention.” For all three interventions, however, self-reported improvements were substantial and were much greater than self-reported improvements after “no intervention.” In other words, dummy treatments made the subjects (report that they) feel better, whereas real medicine not only made them feel better but actually made them better.

Before proceeding, let me offer a couple of caveats. First, the word “doctors” in the flippant title of this post refers mainly to two individuals: Daniel Moerman, PhD, the anthropologist who wrote the accompanying editorial, and Ted Kaptchuk, the Senior Author of the trial report. It does not refer to any of the other authors of the report. Second, I have no quarrel with the trial itself, which was quite good, or with the NEJM having published it, or even with most of the language in the article, save for the “spin” that Dr. Gorski has already discussed.

My quarrels are the same as those expressed by Drs. Gorski and Novella, and by all of us on the Placebo Panel at TAM. This post and the next will develop some of those points by considering the roles and opinions of Moerman and Kaptchuk, respectively.

A True Story

Late one night during the 1960s a friend and I, already in a cannabis-induced fog, wandered into a house that had been rented by one of his friends. There were about 8-10 ‘freaks’ there (the term was laudatory at the time); I didn’t know any of them. The air was thick with smoke of at least two varieties. After an uncertain interval I became aware of a guy who was having trouble breathing. He was sitting bolt upright in a chair, his hands on his knees, his mouth open, making wheezing sounds. He took short noisy breaths in, followed by what seemed to be very long breaths out, as though he was breathing through a straw. You could hear the wheezing in both directions. Others had also noticed that he was in distress; they tried to be helpful (“hey, man, ya want some water or somethin’?”), but he just shook his head. He couldn’t talk. My friend, who had asthma himself, announced that this guy was having an asthma attack and asked if he or anyone else had any asthma medicine. No one did.

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Posted in: Acupuncture, Cancer, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Health Fraud, Homeopathy, Medical Academia, Medical Ethics, Naturopathy, Pharmaceuticals, Public Health, Science and Medicine, Science and the Media

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An open letter to NIH Director Francis Collins regarding his appearance at the Society for Integrative Oncology

Note from the editor: Since today is a holiday in the U.S., I had planned on taking the day off. Then I saw the subject of today’s post and had to respond. Also, please remember that, as always, the usual disclaimers apply. This letter represents my opinion, and my opinion alone. It does not represent the view or opinion of my university or cancer center—or anyone else, for that matter, other than me.

Francis S. Collins, MD, PhD
Director, National Institutes of Health

Dear Dr. Collins:

I am normally not one for writing open letters, but in this case I feel compelled to make an exception. This letter will have little or nothing to do with what seems to be the usual criticism leveled against you, namely your intense religious faith and claims. Personally, as a physician and scientist I don’t much care about what religion you follow and, unlike some writers such as Sam Harris, most definitely do not consider your strong Christian faith a disqualification for holding the position that you now hold. All I care about in an NIH director is how well he or she shepherds the scientific mission of the NIH and runs the organization. As a past (and hopefully future) NIH grantee, I want the NIH to fund and support only the most rigorous science and to be a well-run organization. Thus far in your tenure, I haven’t seen any anything major to worry about on that score.

Recently, however, I was very disappointed to discover that you will be the keynote speaker at the 8th International Conference of the Society of Integrative Oncology (SIO) in November. I hope that, when you agreed to accept this speaking engagement, you didn’t know just what it is that what you were accepting or what the Society for Integrative Oncology is, other than a professional society that was interested in hearing your views on faith and spirituality in cancer. In brief, it is our position that “integrative oncology” is a discipline that, at its core, is dedicated to “integrating” pseudoscience with science. No doubt you will think I am exaggerating, but I am not, as I hope to demonstrate. Worse, by agreeing to speak to the SIO, you will be providing it with the imprimatur of your position as NIH director. The NIH, as you know, is the most respected biomedical research institution in the U.S., if not the world, and that respect rubs off wherever you speak.
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Posted in: Faith Healing & Spirituality, Politics and Regulation, Science and the Media

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A University of Michigan Medical School alumnus confronts anthroposophic medicine at his alma mater

I graduated from the University of Michigan Medical School in the late 1980s. If there’s one thing I remember about the four years I was there, it’s that U. of M. was really hardcore about science back then. In fact, one of the things I remember is that U. of M. was viewed as being rather old-fashioned. No new (at the time) organ system approach for us! Every four weeks, like clockwork, we’d have what was called a concurrent examination, which basically meant that we were tested (with multiple choice tests, of course) on every subject on the same morning. The medical curriculum for the first two years had been fairly constant for quite some time, with a heaping helpin’ of anatomy, histology, biochemistry, and physiology in the first year and the second year packed full of pharmacology, pathology, and neurosciences. Nowhere to be found was anything resembling “energy medicine” or anything that wasn’t science-based!

Of course, back in the 1980s, the infiltration of quackademic medicine into medical schools and academic medical centers hadn’t really begun in earnest yet, although the rumblings of what is now called “complementary and alternative medicine” (CAM) and, more frequently these days, “integrative medicine” (IM) were starting to be heard in East Coast and West Coast schools. Even there, though, the incipient CAM movement was viewed as fringe, not worthy of the attention of serious academic physicians. Indeed, in the late 1980s, even at what are now havens of quackademic medicine if someone had suggested that diluting substances until there is nothing left, as in homeopathy, or waving your hands over a patient in order to channel the “universal source” of energy into a patient in order to heal a patient, as in reiki, had any place in scientific medicine, he’d have been laughed out of medical school–and rightly so.

Not so today, unfortunately. Although the problem of infiltration of quackademic medicine into academic medical centers goes way beyond this example, I can point out that faith healing based on Eastern mystical beliefs instead of Christianity is alive and well and ensconced in academic medical centers such as the University of Maryland School of Medicine Center for Integrative Medicine, where reiki masters are roaming the halls of the University of Maryland R. Adam Cowley Shock Trauma Center and Bonnie Tarantino, a Melchizedek practitioner, holographic sound healer, and an Usui and Karuna Reiki Master holds sway. Meanwhile, all manner of woo, such as acupuncture, homeopathy, craniosacral therapy, reiki, and reflexology are offered. Truly, you know that when an academic medical center has gone so far as to offer homeopathy, reflexology, and reiki, it’s all over as far as academic credibility is concerned, and it has become a center of quackademic medicine. Sadly, even a hospital where I trained, MetroHealth Medical Center, has succumbed to the temptation to add the quackery that is reiki to its armamentarium. That aside, I had never expected that my old, hardcore University of Michigan would go woo in such a big way.

I was wrong.
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Posted in: Faith Healing & Spirituality, Homeopathy, Medical Academia, Religion

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Of SBM and EBM Redux. Part IV: More Cochrane and a little Bayes

NB: This is a partial posting; I was up all night ‘on-call’ and too tired to continue. I’ll post the rest of the essay later…

Review

This is the fourth and final part of a series-within-a-series* inspired by statistician Steve Simon. Professor Simon had challenged the view, held by several bloggers here at SBM, that Evidence-Based Medicine (EBM) has been mostly inadequate to the task of reaching definitive conclusions about highly implausible medical claims. In Part I, I reiterated a fundamental problem with EBM, reflected in its Levels of Evidence scheme, that although it correctly recognizes basic science and other pre-clinical evidence as insufficient bases for introducing novel treatments into practice, it fails to acknowledge that they are necessary bases. I explained the difference between “plausibility” and “knowing the mechanism.”

I showed, with several examples, that in the EBM lexicon the word “evidence” refers almost exclusively to the results of clinical trials: thus, when faced with equivocal or no clinical trials of some highly implausible claim, EBM practitioners typically declare that there is “not enough evidence” to either accept or reject the claim, and call for more trials—although in many cases there is abundant evidence, other than clinical trials, that conclusively refutes the claim. I rejected Prof. Simon’s assertion that we at SBM want to “give (EBM) a new label,” making the point that we only want it to live up to its current label by considering all the evidence. I doubted Prof. Simon’s contention that “people within EBM (are) working both formally and informally to replace the rigid hierarchy with something that places each research study in context.”

In Part II I responded to the widely held assertion, also held by Prof. Simon, that there is “societal value in testing (highly implausible) therapies that are in wide use.” I made it clear that I don’t oppose simple tests of basic claims, such as the Emily Rosa experiment, but I noted that EBM reviewers, including those employed by the Cochrane Collaboration, typically ignore such tests. I wrote that I oppose large efficacy trials and public funding of such trials. I argued that the popularity gambit has resulted in human subjects being exposed to dangerous and unethical trials, and I quoted language from ethics treatises specifically contradicting the assertion that popularity justifies such trials. Finally, I showed that the alleged popularity of most “CAM” methods—as irrelevant as it may be to the question of human studies ethics—has been greatly exaggerated.

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Posted in: Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Medical Academia, Medical Ethics, Science and Medicine

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Dr. Mehmet Oz completes his journey to the Dark Side

A couple of weeks ago, both Steve Novella and I criticized Dr. Mehmet Oz (a.k.a. “America’s doctor”) for not only hosting a man I consider to be a major supporter of quackery, but going far beyond that to defend and promote him. After that, I considered Dr. Oz to be a lost cause, with nothing to excuse him for his having embraced a man whose website is a wretched hive of scum and quackery almost as wretched as NaturalNews.com (in my opinion, of course). Unfortunately, apparently Dr. Oz’s defense of Dr. Mercola was only the beginning of the end of whatever minimal credibility Dr. Oz had left as a practitioner of evidence-based medicine.

This week, Dr. Oz put the final nails in the coffin of his credibility as a practitioner of science-based medicine. I realize that some would argue that he did that long ago. Fair enough. However, I always held out some hope that he might stop mixing pseudoscience like reiki with science. Then he embraced Dr. Joseph Mercola. Strike one! Unfortunately, strikes two and three followed over the last week or so.
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Posted in: Faith Healing & Spirituality, Religion, Science and the Media

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