I’ve spent the last three weeks writing about a “brave maverick doctor” by the name of Stanislaw Burzynski who claims that he can cure cancers that regular oncologists cannot. He uses a combination of what he calls “antineoplastons” (which, it turns out, are more or less than the active metabolites of an orphan drug known as sodium phenylbutyrate) plus a very expensive cocktail of chemotherapy and targeted agents chosen in a haphazard fashion and thrown together with little rhyme or reason. This week, I had planned to move on. However, I felt that I had to mention the Burzynski saga because it provides me with the most appropriate segue to a topic I’ve been meaning to write about for a long time, possibly since this blog began. In fact, it’s about as perfect a framework as I can think of upon which to drape the points I want to make in this post.
What I will discuss is perhaps the most effective, devastating attack that proponents of quackery, woo, and nonsense aim at supporters of science-based medicine (SBM). As far as that is the case, it is not effective because it’s fact-based, evidence-based, or science-based. Far from it. Rather, it’s effective because it appeals to the emotions and very effectively demonizes SBM proponents to the point where they often have a hard time standing their ground when it is used. Sometimes, it preemptively prevents them from even speaking up in the first place. It’s a little tactic that I like to call the “compassion gambit,” which means trying to discredit critics of “alternative” medicine by painting them as cold, unfeeling, uncaring, arrogant monsters who want to hurt or kill children (and probably get a big smile on their faces when they torture puppies, to boot).
It is hard to Sokalize alternative medicine. The closest has been buttock reflexology/acupuncture, but that is a tame example. Given the propensity for projections of the human body to appear on the iris, hand, foot, tongue, and ear, postulating a similar pattern on the buttocks are simple variations on a common SCAM (Supplements, Complementary and Alternative Medicine) theme. The buttocks? Not really different from any of the other focal acupunctures. Most of SCAM does not concern itself with application of reality and physiology, anatomy, biochemistry, etc can all be expected to be ignored with virtually all SCAM modalities.
Every time I think the heights (or depths) of absurdity has been reached, I discover a Braco the Starer or Himalayan Salt Inhalers. This blog is not affiliated with the British Medical Journal in any way, and although this is being published near Christmas, I want no one think that what follows is a hoax. I am not, I repeat not, making up what follows. It is not fiction. Well, it is fiction, but not written by me and believed and practiced by some who really should know better.
At SBM our mission is to promote the highest standards of science in medicine, and to explore exactly what that means, both in the specific and the general. We do spend a lot of space criticizing so-called CAM (complementary and alternative medicine) because it represents a semi-organized attempt to reduce or even eliminate the science-based standard of care, and to sow confusion rather than clarity as to how science works and what the findings of medical science are.
CAM proponents tend to use the same bad arguments over and over again. They have no choice (other than deciding not to be CAM proponents) – if a treatment were backed by solid logic and evidence it would not be CAM, it would just be medicine. As SBM’s fourth year comes to a close I thought I would round up the most common bad arguments that CAM proponents put forward to defend their position. Like creationists, pointing out the errors in their facts and logic will not stop them from continuing to use these arguments. But this lack of imagination on their part makes it somewhat easy to counter their arguments, since the same ones will come up again and again.
The argument from antiquity
Our SBM colleagues in Australia have been critical of the incorporation of unscientific methods into academia. In defense of this practice:
Professor Iain Graham from Southern Cross University’s School of Health yesterday defended his university, saying the use of alternative therapies, such as homeopathy, can be traced as far back as ancient Greece.
This is a common claim – that some CAM modalities have been around for centuries, or even thousands of years, and so they must work. I am not sure if professor Graham intended to state that homeopathy can be traced back to ancient Greece, perhaps he just meant that some CAM therapies can, and chose homeopathy as a bad example. For the record, homeopathy was invented by Samuel Hahnemann about 200 years ago.
Several of us have written about how contemporary quacks have artfully pitched their wares to a higherbrow market than their predecessors were accustomed to, back in the day. Through clever packaging,* quacks today can reasonably hope to become professors at prestigious medical schools, to control and receive substantial grant money from the NIH, to preside over reviews for the Cochrane Collaboration, to be featured as guests and even as hosts on mainstream television networks and on PBS, to issue opinions in the name of the National Academy of Sciences, to be patronized by powerful politicians, and even to be chosen by U.S. presidents to chair influential government commissions.
The most successful pitch so far, and the one that the fattest quack-cats of all have apparently decided to bet the farm on, is “integrative medicine” (IM). Good call: the term avoids any direct mention of the only thing that distinguishes it from plain medicine. Its proponents, unsurprisingly, have increasingly come to understand that when they are asked to explain what IM is, it is prudent to leave some things to the imagination. They’re more likely to get a warm reception if they lead people to believe that IM has to do with reaching goals that almost everyone agrees are worthy: compassionate, affordable health care for all, for example.
In that vein, the two most consistent IM pitches in recent years—seen repeatedly in statements found in links from this post—are that IM is “preventive medicine” and that it involves “patient-centered care.” I demolished the “preventive” claim a couple of years ago, as did Drs. Lipson, Gorski, and probably others. Today I’ll explain why the “patient-centered care” claim is worse than fatuous.
Michael Specter is a good science journalist. I particularly enjoyed his book, Denialism. In a recent New Yorker article he tackles the difficult question of the placebo effect in modern medicine. While he does a fair job of hitting upon the key points of this question, I think he missed some important aspects of this question and allowed the views of Ted Kaptchuk to overly influence the framing of the article. Specter fell for the typical journalist trap — frame the article around a charismatic “maverick”, complete with compelling anecdotes, bury the meat of legitimate skepticism deep in the article, but then bring it all back to the maverick in the end. Be sure to tell us how this is going to change everything. This is good story telling, but very problematic as science journalism.
Kaptchuk himself is an interesting character. He is heading Harvard’s Program in Placebo Studies and the Therapeutic Encounter. He has produced some good science on the placebo effect, but does not seem to want to draw the appropriate lessons from that research, and passes his bias on to Specter. From the article the quotes from Kaptchuk that most strike me are those about his personal experience with placebo medicine. Specter reports:
“There was no fucking way needles or herbs did anything for that woman’s ovaries,” he told me, still looking mystiﬁed, thirty-ﬁve years later. “It had to be some kind of placebo, but I had never given the idea of a placebo effect much attention. I had great respect for shamans—and I still do. I have always believed there is an important component of medicine that involves suggestion, ritual, and belief—all ideas that make scientists scream. Still, I asked myself, Could I have cured her? How? I mean, what could possibly have been the mechanism?”
I have never belonged to the American Medical Association. As a student I didn’t want to pay the dues. As a practicing physician I am of the opinion that the AMA has two often mutually exclusive goals (promoting physician income and patient care) and they are doing both badly.
In the 1990’s the AMA entered into a contract with Sunbeam to get an AMA seal of approval for Sunbeam products, but due to objections the AMA backed out of the deal, in the end costing them almost 10 million dollars.
As was noted at the time:
“I think if we’d gone to trial,” Dr. Relman said on Saturday, ”probably a lot more relevant information would have been uncovered and made available to the membership. As a result of this settlement, we will never know the truth of what happened. It does not let the sun shine in.”
Yeah AMA. It is probably for good reason that only around 29% f of US physicians belong to the AMA; I have never seen them as representing me or my patients. Whether the AMA or physicians, I am automatically suspicious of any person or institution who puts their seal of approval on a product. I figure they are only doing it for the money. Not that there is anything wrong for that; I am for sale if anyone can meet my price. Trusting endorsements is like George Carlin’s (I think) observation that he did not like doing standup for stoners since you never know if was the act or the dope that lead to the laughter. I know celebrities are paid for their endorsements; it is not conflict of interest when it is your job to sell a product. At least actors say they only play a doctor on TV. But when professionals use their authority to recommend products, I would love to see a conflict of interest statement in the recommendation.
When I give a lecture I have to mention my conflicts of interest (COI)* and I have to specifically confirm or deny that I will mention products in which I have a financial interest^. The COI rules are nice, so you know, sort of, who has an interest in pleasing their corporate masters, although I suspect most doctors do not take COI statements seriously. At IDSA this year most of the speakers gave their COI statements with a short, dismissive sneer and a roll of the eyes. Me? Potentially Biased? Puh-please. (more…)
An recent article in the journal Ophthalmology reported the results of a clinical trial that evaluated acupuncture as an adjunctive treatment for anisometropic amblyopia. In the abstract, the authors conclude:
Acupuncture is a potentially useful complementary treatment modality that may provide sustainable adjunctive effect to refractive correction for anisometropic amblyopia in young children. Further large-scale studies seem warranted.
A little background information is in order.
In a healthy visual system the various structures in the eye focus light ambient light to form a sharp image on the retina. The retina functions like the CCD in a digital camera. Light energy is transduced to electrical signals, which are transmitted through the optic nerve. The signals from the optic nerve are relayed to the occipital cortex (at the very back of the brain) where they are interpreted into the experience of vision.
Amblyopia is often called “lazy eye”. If during childhood the brain is deprived of quality visual information it does not mature properly and loses the potential for good vision. Any opacity within the eye which significantly degrades the quality of the image forming on the retina (such as congenital cataract) can cause amblyopia. Strabismus (misalignment of the 2 eyes) can also cause amblyopia. If the eyes are not aligned, the brain has difficulty reconciling the disparate images from the 2 eyes. In order to avoid double vision the brain may “ignore” the input from one eye, and corresponding part of the visual cortex will not develop properly. Extreme, uncorrected, refractive errors (nearsightedness, farsightedness or astigmatism) can cause amblyopia. Patients with different refractive errors in their 2 eyes, a condition known as anisometropia, can also develop amblyopia in one eye.
Multivitamin supplementation has been getting a rough ride in the literature, as evidence emerges that routine supplementation for most is, at best, unnecessary. Some individual vitamins are earning their own unattractive risk/benefit profiles: Products like folic acid, calcium, and beta-carotene all seem inadvisable for routine supplementation in the absence of deficiency or medical indication. Vitamin E, already on the watch list, looks increasingly problematic, with data recently published confirming the suspected association of supplementation with an elevated risk of prostate cancer.
Reading through the vitamin posts here at SBM, one issue comes through repeatedly: The danger of assuming therapeutic benefits in the absence of confirmatory evidence. Vitamin supplement have the patina of safety and of health, a feature that’s reinforced when you purchase them: You don’t need a prescription, you don’t get counseled on their use, and there isn’t a long list of frightening potential side effects to accompany the product. You can pull a bottle off the shelf, and take any dose you want. After all, how harmful can vitamins be when you can buy 5 pounds of vitamin C at a time, or vitamin E capsules in a 1000-pack? But the research signals seem to be getting stronger, and most are pointing in the same direction: what we though we knew about antioxidants was based on simplistic hypotheses about nutrition and health. And while we thought we were doing ourselves good with antioxidant supplements, we may have been doing harm. (more…)
Prince Charles is a big supporter of “natural” medicine, which in practice means unscientific and ineffective medicine. He has no particular expertise in this area, and there is absolutely no legitimate reason why he should have any influence over the practice of medicine in the UK. But he is the Prince of Wales, and he has chosen to use that celebrity to promote CAM.
Prince Charles has also recently been criticized for his credulous support for medical nonsense. The Telegraph recently reported that Simon Singh, co-author with Edzard Ernst of Trick or Treatment, and exposer of CAM pseudoscience, spoke about Prince Charles at the recent Hay Festival in India. Singh had some sharp criticism, including:
He only wants scientific evidence if it backs up his view of the natural treatment of health conditions…
We presented evidence that disputes the value of alternative medicine and despite this he hasn’t changed his mind…
Every so often, I come across studies that leave me scratching my head. Sometimes, these studies are legitimate scientific studies that have huge flaws or come from an assumption that is very off-base. Other times, they involve what Harriet Hall has termed “tooth fairy science,” wherein the tools of science are used to study a phenomenon that is fantastical, whose very existence hasn’t been demonstrated. Many such studies, not surprisingly, are studies of “complementary and alternative medicine” (CAM) or “integrative medicine” (IM). Modalities like reiki (which is faith healing that substitutes Eastern mysticism for Christian beliefs) and homeopathy (which is, when you boil it down to its essence, sympathetic magic) fall into the category of therapeutic modalities that are based on fantasy but are studied as with the latest tools of science, producing no end to confusing noise. This “tooth fairy science” has, over the last few years, reached its epitome in the application of the latest genomics technology to, in essence, magic, and I’ve recently come across an incredible example of just such a thing. But, first, let’s take a step back to what is going on in medical science now before I introduce a concept that I’ve dubbed “woo-omics.”
A prelude to woo-omics: Genomics, proteomics, everywhere an “omics”
One of the most difficult problems in science-based medicine is how to do a better job identifying which patients will respond to which treatments. Clinical trials, by their very design, have to look at average responses in populations. In essence, a treatment is compared to either placebo or standard-of-care, a choice mainly driven by ethics and whether effective treatments exist for the condition being studied. It is then determined using statistics whether a significant difference exists between the two groups. The difficulty, as any clinician knows, is applying the results of clinical trials to individual patients. In any population, there is, after all, a range of responses to any drug or treatment, and it would be desirable to be able to predict which patients will fall at the end of the bell-shaped curve where the treatment is most effective and which will fall at the end of the curve where the treatment works poorly or not at all.