The interwebs are more than a series of tubes, it has the power of endless distraction and tangents, a series of clickable rabbit holes that can drag you deeper and deeper into the alternative universes that are parallel with our own. One moment you can be on Science Based Medicine, grounded on the terra firma of reality, and then with a click of the mouse you can lose your way in the electronic warren.
It started as an advertisement on a skeptical website, perhaps SBM, perhaps not. The entrances to rabbit holes are Hogwartian in nature, never being in the same place twice. It is how I remember it.
Google serves up ads based on what their algorithm perceives as the content of the website. The algorithm lacks a certain, shall we say, nuance, and fails to understand that advertisements suggesting training in homeopathy or the promoting the practice of chiropractic may not have a close relationship to the content of Science Based Medicine. Still the ad did intrigue me, as it mentioned that the practitioner was Oregon’s only MD Acupuncturist. So I clicked. (more…)
We have an active comments section on our blog, but for some reason some people prefer not to comment there, but to send personal e-mails to authors when they disagree. Some of them make me laugh. Some of them make me despair. We can carry on our struggle better if we know what we are fighting; and in that spirit, I want to describe a recent e-mail exchange.
If an e-mail is filled with angry CAPITALS and abusive language, I know there is no point in responding. But I still get suckered in by the ones that start out sounding as if a productive dialog might be possible; unfortunately, discussions almost always degenerate. In this case, it started with a polite request for my opinion about a specific study. (more…)
I was asked to write an article for Slate, the on-line magazine, about Andrew Weil’s selection as the keynote speaker for the 2012 AAFP annual scientific assembly. The science and health editor, Laura Helmuth, was initially enthusiastic about what I wrote, but eventually decided not to publish it. Here is the initial draft of my article. My comments follow.
Original Draft of Article for Slate
The American Academy of Family Physicians picked Andrew Weil to be the keynote speaker at its annual scientific assembly October 16-20 in Philadelphia. What were they thinking? That’s like having an astrologer give the keynote speech at an astronomy meeting.
The AAFP stands for the best in conventional medicine, for the standard of care as determined by physicians and scientists. Weil doesn’t. The AAFP stands for evidence-based medicine. Weil doesn’t. (more…)
Topics, as I noted a fortnight ago in my uniquely misspelled and ungrammatical way, never die**. Or even fade away. There are popular ideas that persist in the world that have little to do with reality. In the reality based world of medicine there are concepts that refuse to die. Atelectasis causing fever or the need to ‘double cover’ Pseudomonas. Neither are true, yet every year medical students tell me that is what they have been taught. It is said the only way new ideas take hold is for those that hold the old ideas to die off. So maybe 50 years from now those medical myths will be gone.
Popular culture also its myths. Take the immune system. Please. It is not a bicep that can be made stronger with a little exercise. It is a complex network of cells and proteins. There are antibodies (IgG (with five subtypes, IgM, IgA, IgE),the complement pathway, polymorphonuclear cells, monocytes, lymphocytes in a profusion that rivals beetles. God, I think, has an inordinate fondness for lymphocytes. There is the Toll system, the cytokines and lymphokines, the non-specific defenses like cilia and mannose binding lectin and on and on and on.
I have a journeyman’s understanding of the immune system, what is needed to understand why a given patient has an infection, although there is little I can do to reverse the immunologic defects: abnormal antibodies from Waldenström’s or low mannose binding lectin levels from liver disease are not amenable to clinical intervention. (more…)
Your health insurance plan probably covers anti-inflammatory drugs. But does it cover acupuncture treatments? Should it? Which health services deliver good value for money? Lest you think the debate is limited to the United States (which is an outlier when it comes to health spending), even countries with publicly-run healthcare systems are scrutinizing spending. Devoting dollars to one area (say, hospitals) is effectively a decision not to spend on something else, (perhaps public health programs). All systems, be they public or private, allocate funds in ways to spend money in the most efficient way possible. Thoughtful decisions require a consideration of both benefits and costs.
One of the consistent positions put forward by contributors to this blog is that all health interventions should be evaluated based on the same evidence standard. From this perspective, there is no distinct basket of products and services which are labelled “alternative”, “complementary” or more recently “integrative”. There are only treatments and interventions which have been evaluated to be effective, and those that have not. The idea that these two categories should both be considered valid approaches is a testament to promoters of complementary and alternative medicine (CAM), who, unable to meet the scientific standard, have argued (largely successfully) for different standards and special consideration — be it product regulation (e.g., supplements) or practitioner regulation.
Yet promoters of CAM seek the imprimatur of legitimacy conferred by the tools of science. And in an environment of economic restraint in health spending, they further recognize that showing economic value of CAM is important. Consequently they use the tools of economics to argue a perspective, rather than answer a question. And that’s the case with a recent paper I noticed was being touted by alternative medicine practitioners. Entitled, Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations, it attempts to summarize economic evaluations conducted on CAM treatments. Why a systematic review? One of the more effective tools for evaluating health outcomes, a systematic review seeks to analyze all published (and unpublished) information on a focused question, using a standardized, transparent approach to evidence analysis. When done well, systematic reviews can sift through thousands of clinical trials to answer focused questions in ways that are less biased than cherry-picking individual studies. The Cochrane Review’s systematic reviews form one of the more respected sources of objective information (with some caveats) on the efficacy of different health interventions. So there’s been interest in applying the techniques of systematic reviews to questions of economics, where both costs and effects must be measured. Economic evaluations at their core seek to measure the “bang for the buck” of different health interventions. The most accurate economic analyses are built into prospective clinical trials. These studies collect real-world costs and patient consequences, and then allow an accurate evaluation of value-for-money. These types of analyses are rare, however. Most economic evaluations involve modelling (a little to a lot) where health effects and related costs are estimated, to arrive at a calculation of value. Then there’s a discussion of whether that value calculation is “cost-effective”. It’s little wonder that many health professionals look suspiciously at economic analyses: the models are complicated and involve so many variables with subjective inputs that it can be difficult to sort out what the real effects are. Not surprisingly, most economic analyses suggest treatments are cost-effective. Before diving into the study, let’s consider the approach:
It is estimated that 5% of people living in Sub-Saharan Africa are infected with HIV – that’s 22.5 million people. Infection rates vary wildly from country to country, with Swaziland having the highest rate at 25.9%. Gambia is below average, at 2% or 18 thousand people, but still has a serious HIV problem, and now finds themselves at the center of the HIV controversy in Africa.
This epidemic has been magnified by unfortunate realities on the ground. Africa has an insufficient public health and medical infrastructure to deal with the massive challenge such an epidemic presents. This has led the World Health Organization to contemplate partnering with local traditional healers, to make them into an extension of the effort to bring modern medical treatment to the HIV-infected in Africa. This desperate strategy is fraught with problems, not the least of which is that most traditional healers have had no prior contact with science-based medicine.
Former South African president Thabo Mbeki seriously set back his country’s HIV efforts by embracing crank HIV denial. Coupled with his denialism was efforts by Health Minister Manto Tshabalala-Msimang to use traditional medicines to treat HIV/AIDS. This combination resulted in restrictions on the distribution of anti-retoviral drugs in South Africa that is estimated to have cost hundreds of thousands of lives.
How are you feeling today? Tired? Is it your active lifestyle wearing you down? Or is it a sign of something more serious? Complaints about fatigue seem ubiquitous. Perhaps it’s a product of a culture with little downtime. Yet from a medical perspective, fatigue can’t be dismissed with a simple instruction to “get more sleep”. When approached in the pharmacy, I take the perspective that anyone actively seeking advice on treatment probably needs a medical assessment. That’s not something I can offer, but I try to impress upon patients the importance of finding the cause, rather than reaching for any quick fix that may be for sale. (5-hour Energy, anyone?) And I can use the opportunity to discuss the appropriate role of supplements for treating fatigue. (more…)
At the recent Amaz!ng (no, the ! is not a typo) Meeting in Las Vegas, Dr. Gorski, Dr. Novella, “Dr. Rachie” (Rachael Dunlop of Australia) and I participated in a workshop on “Dr. Google” about how to find reliable health information on the Internet. In my presentation, I described step by step how I researched a typical diet supplement product, Procera AVH. Later, one of our readers wrote to ask us about that very product, so I decided to convert part of my presentation into this blog post.
A half-page spread in my local newspaper proclaimed: “Memory Pill Does for the Brain What Prescription Glasses Do for the Eyes, Claims US Surgeon General Candidate.” It looked superficially like a news report, but it was actually an advertisement for the diet supplement Procera AVH. Closer inspection revealed the words “Paid advertisement” in tiny print, the required FDA disclaimer for diet supplements, a “Call Toll-Free” number and offers of a FREE Bonus Bottle, FREE book, and FREE supply of Rapid Detox Formula for First 500 Callers. (more…)
Having spent many evenings and weekends working in a retail pharmacy with a thriving vitamin and supplement aisle, I’m no longer surprised at the purchasing habits of consumers. The setting gave me not only the opportunity to learn about the latest supplement fads, but also to speak with consumers that place great faith in these products. A recent paper suggests 25% of CAM users account for 75% of all expenditures on CAM. And that’s consistent with what I saw in the pharmacy. Some consumers spend hundreds per month on supplements, so the belief that these products are beneficial must be very strong. So I like to ask about reasons for use. Many attribute their current health status to supplements, and usually tell me that their supplements are for preventing disease, optimizing health, or “boosting” the immune system. And while I’m encouraged to see these consumers take an active interest in maximizing their own health, I’m often puzzled by the decision-making that’s occurring. In some cases, beliefs about health, medicine, or the effectiveness of their supplements are misguided, or flat-out wrong. They’re getting expensive urine and positive feelings, but there’s little evidence to suggest the supplementing is having any objective benefits. More surprisingly, some consumers take products for which there is no medical indication at all – it’s intended as “primary prevention” of a medical condition they believe they can avoid through supplement use. Afraid of macular degeneration? Take lutein. Or worried about Alzheimer’s? Grab some ginkgo biloba. No matter your anxiety, there’s a supplement marketed for your. One supplement with enduring popularity is magnesium. It cures cancer. And depression. Throw away your inhalers, because it cures asthma too. Read enough online, and you’ll conclude that magnesium is quite possibly the prevention and the cure to all disease. (more…)
One of the points I’ve tried to emphasize through my contributions to Science-Based Medicine is that every treatment decision requires an evaluation of risks and benefits. No treatment is without some sort of risk. And a decision to decline treatment has its own risks. One of the challenges that I confront regularly as a pharmacist is helping patients understand a medication’s expected long-term benefits against the risks and side effects of treatment. This dialogue is most challenging with symptomless conditions like high blood pressure, where patients face the prospect of immediate side effects against the potential for long-term benefit. One’s willingness to accept side effects is influenced, in part, by and understanding of, and belief in, the overall goals of therapy. Side effects from blood-pressure medications can be unpleasant. But weighed against the reduced risk of catastrophic events like strokes, drug therapy may be more acceptable. Willingness to accept these tradeoffs varies dramatically by disease, and are strongly influenced by patient-specific factors. In general, the more serious the illness, the greater the willingness to accept the risks of treatment.
As I’ve described before, consumers may have completely different risk perspectives when it comes to drug therapies and (so-called) complementary and alternative medicine (CAM). For some, there is a clear delineation between the two: drugs are artificial, harsh, and dangerous. Supplements, herbs and anything deemed “alternative”, however, are natural, safe, and effective. When we talk about drugs, we use scientific terms – discussing the probability of effectiveness or harm, and describing both. With CAM, no tentativeness or balance may be used. Specific treatment claims may not be backed up by any supporting evidence at all. On several occasions patients with serious medical conditions have told me that they are refusing all drug treatments, describing them as ineffective or too toxic. Many are attracted to the the simple promises of CAM, instead. Now I’m not arguing that drug treatment is always necessary for ever illness. For some conditions where lifestyle changes can obviate the need for drug treatments, declining treatment this may be a reasonable approach – it’s a kick in the pants to improve one’s lifestyle. Saying “no” may also be reasonable where the benefits from treatment are expected to be modest, yet the adverse effects from treatments are substantial. These scenarios are not uncommon in the palliative care setting. But in some circumstances, there’s a clear medical requirement for drug treatment – yet treatment is declined. This approach is particularly frustrating in situations where patients face very serious illnesses that are potentially curable. This week is the World Cancer Congress in Montreal and on Monday there were calls for patients to beware of fake cancer cures, ranging from laetrile, to coffee enemas, to juicing, and mistletoe. What are the consequences of using alternative treatments, instead of science-based care, for cancer? There are several studies and a recent publication that can help answer that question. (more…)