I quite like Portlandia. I find it funny and it captures a part of Portland. I recognize large swaths of the city’s culture in the show. Other representations of the city I recognize less. Sunset publishes beautiful photographs of the NW, but when I look at the photos I think, that section of the city never looks that good. It is quite wonderful how Photoshop can improve on reality.
Like most major cities, Portland has a monthly magazine, Portland Monthly. The city represented in that magazine is mostly alien to me. I look at the advertisement, the articles, the photographs, and wonder when did Portland become a city with an average 7 figure income? The Portland in which I grew up and currently live is rarely found in the pages of Portland Monthly. If you are extremely well to do, I suppose you are in the demographic Portland Monthly. But when I flip through the pages of the magazine, I see little I recognize, but I have never completely abandoned the hippie/grunge aesthetic of my younger days.
Every January they have the best Doctors issue* and this year, for the first time, they offer The Portland Alternative Medicine Guide. Well, less a guide and more an extended infomercial filled with ‘facts’ that deserve the quotes. (more…)
The ancient Greeks posited a system of health and disease based on the four humors: blood, phlegm, black bile and yellow bile. According to this system, health is defined as a harmony of these four humors and disease is caused by an imbalance among them. Restore the balance, and health is restored. Bleeding is a familiar example of humoral medical treatment based on a diagnosis of an “excess” of blood. Fortunately, the humoral system of diagnosis and treatment died out with the advent of modern scientific medicine.
But as David Gorski asked (sarcastically, of course) in his presentation on quackademic medicine at CSICon in October, if supposedly ancient philosophies of diagnosis and treatment such as Traditional Chinese Medicine and Ayurveda are so beloved by CAM proponents, despite their implausibility and lack of evidence of effectiveness, why not the humoral model of health and disease? Why not include humorism in the CAM practitioner armamentarium?
Quacks detest science-based medicine (SBM) in general, but there are certain specialties that they detest more than others. For instance, you won’t find too many quacks attacking trauma surgery because even they know that when a person’s body has been on the losing end of a confrontation with a bullet or a car, no amount of laying on of hands, homeopathic nostrums, “energy healing,” or herbal remedies are going to stop the hemorrhage, mend broken bones, or repair holes in various internal organs. That’s why even homeopaths will concede that “allopathic medicine” is good for emergencies. It’s also why sketches like this one resonate:
However, from there the distrust of promoters of unscientific and pseudoscientific medical systems and treatment modalities for SBM appears to increase in direct proportion to the urgency and need for direct physical repair of damaged organs, with the possible exception of cancer, for which the standard physical treatment (surgery) is attacked nearly as much as chemotherapy.
Be that as it may, arguably the specialty most attacked by quacks is psychiatry. Many are the reasons, some legitimate, many not. For example, the Church of Scientology in particular despises psychiatry, even going so far as to maintain through its anti-psychiatry front group the Citizens’ Commission on Human Rights (CCHR) a risibly nonsensical “museum” in Hollywood dedicated to psychiatry that they charmingly call Psychiatry: An Industry of Death. It’s so ridiculously, painfully over-the-top, a veritable self-parody of anti-psychiatry hyperbole, that it inadvertently undermines the very attacks on psychiatry frequently leveled by Scientologists and quacks that it’s meant to reinforce. Indeed, not having visited its website for several years, I notice that the CCHR has totally revamped it, now including a virtual 3D tour of the museum, along with video clips from its many “exhibits” available online. I’ll have to file that away for later blog fodder, because the misinformation, cherry picking, and pseudoscience flow freely, as one would expect from a Scientology propaganda project. In the meantime, suffice to say that it’s not just the Church of Scientology that despises psychiatry. It’s founder L. Ron Hubbard and his disciples merely represent the most ridiculously over-the-top and vociferous anti-psychiatry group that I’m currently aware of.
Let’s face it, psychiatry hasn’t always had the best history. It’s a very hard to study human behavior and disorders of human behavior in a rigorous fashion, but to my mind that didn’t excuse the the widespread acceptance for many decades of the ideas of Sigmund Freud, which were little removed from pseudoscience in many respects. Also, psychiatry has not always had the best history, particularly in the early part of this century. Too often, psychiatry has been used as a tool of control rather than a means of helping people who are suffering. Perhaps the worst example is the misuse of psychiatry by various totalitarian regimes, be it the Nazis using it as a primary tool of its T4 euthanasia program or the Soviet Union declaring enemies of the state to be mentally ill and shipping them off to Gulags.
Although there is a ways to go, however, psychiatry in 2012 is much better than psychiatry, say, 50 or 75 years ago. It wasn’t so long ago that, popularized by Walter Freeman, thousands of “ice pick lobotomies” were performed for all manner of indications, few of which had what we would consider to be compelling scientific support to back them up. Over the last half-century, better psychiatric drugs to treat different conditions have been developed, leading to their widespread use for a number of indications. (more…)
Earlier this year, Australia’s anti-vaccine lobby, the Australian Vaccination Network (AVN), took the NSW Government to the Supreme Court. In dispute was their license to fundraise which had been revoked and a public warning, issued because they refused to put a Quack Miranda on their website.
The public warning was posted after the NSW government investigated their website following two complaints, one from a concerned citizen and one from the parents of a 4 week old girl who had died of pertussis.
The complaints accused the AVN of peddling dangerous health misinformation including that vaccines were linked to autism and that pertussis was “nothing more than a bad cough”.
The AVN had always insisted that the HCCC did not have jurisdiction over them because they were not health care providers or educators in the “traditional sense”. It is true that health legislation in NSW is very much out of date in the Internet age. The rules say you can complain only if you can demonstrate direct harm as a result of taking someone’s dodgy advice. For example you had a stroke because of a chiropractor’s adjustments or a punctured lung from acupuncture. Just having a website full of woo-woo wasn’t really covered.
So the AVN challenged the HCCC on these grounds and, to the surprise of many of us, they won. Those who were present in the court that day recall the Judge urging the HCCC Barrister to present evidence for direct harm. And the worst thing was the HCCC apparently had this information, but for reasons unknown to us, did not present it. Those who were there said the HCCC Barrister dropped the ball big time that day. And they were right.
Within hours the public warning was expunged and shortly after that the authority to fundraise was returned. As if nothing ever happened. (more…)
As regular readers of the blog are aware, I am science/reality based. I think the physical and basic sciences provide an excellent understanding of reality at the level of human experience. Physics, chemistry, biology, anatomy, biochemistry, physiology, evolution etc. provide a reliable and reproducible framework within which to understand health and disease. My pesky science may not know everything about reality, but day to day it works well.
“There are more things in heaven and earth, Horatio, Than are dreamt of in your philosophy. – Hamlet (1.5.166-7).”
Perhaps, but all the medical advances in my lifetime have been not yielded new science, just (amazing) variations and extensions of known processes. I sometimes think the blog should have been called reality based medicine, but science is the tool by which we understand reality, and while the tool is constant, our understanding of reality is prone to changing. An understanding of the rules of the universe combined with an awareness of the innumerable ways whereby we can fool ourselves into believing that those rules do not apply to us is part of what makes a science and reality based doctor.
We are often told of the need to keep an open mind, but I like to keep it open to reality. Not that I do not like fantasy and magic, it is a common category for my reading. I just finished Red Country by Joe Abercrombie, and while I love the world he has created, I would not want to apply the rules of that imaginary world to my patients. Well, one exception. As Logen Ninefingers would say, “You have to realistic about these things.” Fictional worlds should be limited to the practice of art, not the practice of medicine. (more…)
Maybe not. But the thought did occur to me while reading the Final Judgment and Order entered in Gallucci v. Boiron, the class action accusing the world’s largest manufacturer of homeopathic products of consumer fraud.
When we refer to “science-based medicine” (SBM), it is a very conscious choice to emphasize that good medicine should be based on a solid foundation of science. The name was coined to contrast the difference between the current evidence-based medicine (EBM) paradigm, which fetishizes randomized clinical trial evidence above all else and frequently ignores prior plausibility based on well-established basic science, and the SBM paradigm, which takes prior plausibility into account. The purpose of this post will not be to resurrect old discussions on these differences, but before I attend to the study at hand I bring this up to emphasize that progress in science-based medicine requires progress in science. That means all levels of biological (and even non-biological) basic science, which forms the foundation upon which translational science and clinical trials can be built. Without a robust pipeline of basic science progress upon which to base translational research and clinical trials, progress in SBM will slow and even grind to a halt.
That’s why, in the U.S., the National Institutes of Health (NIH) is so critical. The NIH funds large amounts of biomedical research each year, which means that what the NIH will and will not fund can’t help but have a profound effect shaping the pipeline of the basic and preclinical research that ultimately leads to new treatments and cures. Moreover, NIH funding has a profound effect on the careers of biomedical researchers and clinician-scientists, as having the “gold standard” NIH grant known as the R01 is viewed as a prerequisite for tenure and promotion in many universities and academic medical centers. Certainly this is the case for basic scientists; for clinician-scientists, having an R01 is certainly highly prestigious, but less of a career-killer if an investigator is unable to secure one. That’s why NIH funding levels and how hard (or easy) it is to secure an NIH grant, particularly an R01, are perennial obsessions among those of us in the biomedical research field. It can’t be otherwise, given the centrality of the NIH to research in the U.S. (more…)
A few weeks ago I reviewed Ben Goldacre’s new book, Bad Pharma, an examination of the pharmaceutical industry, and more broadly, of the way new drugs are discovered, developed and brought to market. As I have noted before, despite the very different health systems that exist around the world, we all rely on private, for-profit, pharmaceutical companies to supply drug products and also to bring newer, better therapies to market. It’s great when there are lots of new drugs appearing, and they’re affordable for consumers and health systems. But that doesn’t seem to be the case. Pipelines seem to be drying up, and the cost of new drugs is climbing. Manufacturers refer to the costs of drug development when explaining high drug prices: New drugs are expensive, we’re told, because developing drugs is a risky, costly, time consuming endeavor. The high prices for new treatments are the price of innovative new treatments, both now and in the future. Research and development (R&D) costs are used to argue against strategies that could reduce company profitability (and presumably, future R&D), be it hospitals refusing to pay high drug costs, or changing patent laws that will determine when a generic drug will be marketed.
The overall costs of R&D are not the focus in Goldacre’s book, receiving only a short mention in the afterword, where he refers to the estimate of £500 million to bring a drug to market as “mythical and overstated.” He’s not alone in his skepticism. There’s a fair number of papers and analyses that have attempted to come up with a “true” estimate, and some authors argue the industry does not describe the true costs accurately or transparently enough to allow for objective evaluations. Some develop models independently, based on publicly available data. All models, however, must incorporate a range of assumptions that can influence the output. Over a year ago I reviewed at a study by Light and Warburton, entitled Demythologizing the high costs of pharmaceutical research, which estimated R&D costs at a tiny $43.4 million per drug – not £500 million, or the $1 billion you may see quoted. Their estimates, however, were based on a sequence of highly implausible assumptions, meaning the “average” drug development costs are almost certainly higher in the real world. But how much higher isn’t clear. There have been at least eleven different studies published that estimate costs. Methods used range from direct data collection to aggregate industry estimates. Given the higher costs of new drugs, having an understanding of the drivers of development costs can help us understand just how efficiently this industry is performing. There are good reasons to be critical of the pharmaceutical industry. Are R&D costs one of them?
Like every state, Oregon is struggling with the unsustainable costs of taxpayer-funded health care programs. In an attempt to tame this beast, Oregon recently established a system of coordinated care organizations, or CCOs, to (as the name suggests) coordinate medical, mental health, and dental care for residents enrolled in Oregon Health Plan, the state’s Medicaid program. The new system requires supervision of this coordinated effort by the participant’s primary care physician (PCP). Not one of the 15 newly-minted CCOs has credentialed a naturopath as a PCP even though naturopaths are licensed as such by the state. Needless to say, the naturopaths are not pleased by this development.
The big stumbling block appears to be the state’s requirement that CCOs practice evidence-based medicine as a cost control measure. Unfortunately for naturopaths, evidence-based medicine is not their strong suit. Apparently scientific plausibility is not much of a concern either.
We have an obligation to the state and to the community that the providers on our panel will deliver the evidence-based care required by the Oregon Health Plan. . . . We need to make sure that all of the providers who are empanelled meet those basic standards of care.
Regular readers of my other blog probably know that I’m into more than just science, skepticism, and promoting science-based medicine (SBM). I’m also into science fiction, computers, and baseball, not to mention politics (at least more than average). That’s why our recent election, coming as it did hot on the heels of the World Series in which my beloved Detroit Tigers utterly choked got me to thinking. Actually, it was more than just that. It was also an article that appeared a couple of weeks before the election in the New England Journal of Medicine entitled Moneyball and Medicine, by Christopher J. Phillips, PhD, Jeremy A. Greene, MD, PhD, and Scott H. Podolsky, MD. In it, they compare what they call “evidence-based” baseball to “evidence-based medicine,” something that is not as far-fetched as one might think.
“Moneyball,” as baseball fans know, refers to a book by Michael Lewis entitled Moneyball: The Art of Winning an Unfair Game. Published in 2003, Moneyball is the story of the Oakland Athletics and their manager Billy Beane and how the A’s managed to field a competitive team even though the organization was—shall we say?—”revenue challenged” compared to big market teams like the New York Yankees. The central premise of the book was that that the collective wisdom of baseball leaders, such as managers, coaches, scouts, owners, and general managers, was flawed and too subjective. Using rigorous statistical analysis, the A’s front office determined various metrics that were better predictors of offensive success than previously used indicators. For example, conventional wisdom at the time valued stolen bases, runs batted in, and batting average, but the A’s determined that on-base percentage and slugging percentage were better predictors, and cheaper to obtain on the free market, to boot. As a result, the 2002 Athletics, with a payroll of $41 million (the third lowest in baseball), were able to compete in the market against teams like the Yankees, which had a payroll of $125 million. The book also discussed the A’s farm system and how it determined which players were more likely to develop into solid major league players, as well as the history of sabermetric analysis, a term coined by one of its pioneers Bill James after SABR, the Society for American Baseball Research. Sabermetrics is basically concerned with determining the value of a player or team in current or past seasons and with predicting the value of a player or team in the future. (more…)