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The Prince of CAM

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…

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Woo-omics

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.
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Posted in: Basic Science, Diagnostic tests & procedures, Medical Academia, Science and Medicine

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November Hodgepodge

There have not been a lot of topics of late that warrant extensive analysis and discussion.  But there are a number of little topics of interest, each worthy of a few paragraphs of discussion, archetypes of issues in medicine, science based and otherwise.

Xigirs. No, it is not whale vomit, but close.

Last month Xigris  was pulled from the market by Lilly.  Yes, I understand the shock. Xigris, we hardly knew ye.   Xigris is the brand name for drotrecogin alfa, or activated protein C.  It is an enzyme in the clotting cascade that is/was given for the treatment of sepsis. (more…)

Posted in: Acupuncture, Energy Medicine, Pharmaceuticals, Science and Medicine

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Pediatrics & “CAM” I: the wrong solution

Oh no!  Not again! The venerable medical journal Pediatrics devotes an entire supplement this month to Pediatric Use of Complementary and Alternative Medicine: Legal, Ethical, and Clinical Issues in Decision-Making.

We sense from the very first sentence that we are in familiar territory:

Rapid increases the use of complementary and alternative medicine (CAM) raise important legal, ethical, clinical, and policy issues. (S150)

“Rapid increases”? And evidence of these “rapid increases?” None cited.

We do, however, see the same shopworn reference to popularity deconstructed elsewhere on SBM. What we learned by actually examining “the large 2007 US survey” which purportedly “revealed that ~4 in 10 adults and 1 in 9 children and youth used CAM products or therapies within the previous year”(S150) is that

…most hard-core CAM modalities are used by a very small percentage of the population. Most are less than five percent. Only massage and manipulation are greater than 10 percent. These numbers are also not significantly different from 10 or 20 years ago — belying the claim that CAM use is increasing.

We also find this definition of “CAM”:

a broad domain of healing resources …other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. (S150)

I’m not sure what it takes to become “intrinsic” to the “politically dominant” healthcare system. If it includes being legal, licensed or covered by public and/or private insurance, that would appear to disqualify dietary supplements, chiropractic, acupuncture, homeopathy, homeopathic products and naturopathy as “CAM” in some, or in some cases all, of the American states.

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Posted in: Acupuncture, Chiropractic, Herbs & Supplements, Homeopathy, Legal, Medical Ethics, Naturopathy, Politics and Regulation, Science and Medicine, Vaccines

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Lessons Learned

I just returned from a trip to Montreal where I spoke at the Lorne Trottier Public Science Symposium, an annual event that David Gorski spoke at a year ago. My topic was “Puncturing the Acupuncture Myth” and the other speakers were Paul Offit, Edzard Ernst, and Bob Park. I was honored to be in such august company; and we were wined, dined, and cossetted: overall, an experience that will count among the high points of my career. In addition to speaking at the Symposium, I was interviewed on the radio; participated in a roundtable discussion with other doctors, scientists and journalists; and was invited to speak to a large freshman chemistry class at McGill University. I told the students a bit about how I came to be the SkepDoc and some of the things I’ve written about, with “Vitamin O” as an example, and I provided 3 “lessons I have learned” from my investigations that are general principles applicable to other fields:

  • Roosters don’t make the sun come up.
  • Never believe one study.
  • The SkepDoc’s Rule of Thumb: when encountering a new or questionable claim, always try to find out who disagrees and why.

My presentation was recorded and is available as a webcast. Scroll down to “2011/11/08 HallOffit” near the bottom and click on the appropriate symbol to the far right. That saves me having to write a post this week. I think SBM readers will find it pertinent to all we discuss here.

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Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.3: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (concluded)

Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.3: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (concluded)

A Loose End

In the last post I wondered if Ted Kaptchuk, when he wrote the article titled “Effect of interpretive bias on clinical research,” had understood this implication of Bayes’s Theorem: that interpretations of most scientific investigations are exercises in inverse probability, and thus cannot logically be done without consideration of knowledge external to the investigation in question. I argued that if Kaptchuk had

…understood the point when he wrote his treatise, he was dishonest in not explaining it and in not citing at least one pertinent article, such as Steven Goodman’s (which I’m willing to bet he had read). If he didn’t understand the point he should have withheld his paper.

In researching more of Kaptchuk’s opinions I’ve discovered that he had certainly read Goodman’s article, but that he either didn’t understand it or preferred to obscure its implications in deference to his ongoing project in belittling scientific knowledge. In a letter to the editor of the Annals of Internal Medicine in 2001, Kaptchuk opined that even if “more trials of distant healing with increased methodologic rigor” were positive, it still would not “be persuasive for the medical community”:

The situation resembles the predicament with homeopathy trials, another seemingly implausible intervention, where the evidence of multiple positive randomized, controlled trials will not convince the medical community of its validity. Additional positive trials of distant healing are only likely to further expose the fact that the underpinning of modern medicine is an unstable balance between British empiricism (in the tradition of Hume) and continental rationalism (in the tradition of Kant).

…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. [Kaptchuk cites the second of the two Goodman articles that I referred to above, discussed here]

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Posted in: Acupuncture, Book & movie reviews, Health Fraud, Legal, Medical Academia, Medical Ethics, Politics and Regulation, Science and Medicine, Science and the Media

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Premature Claims for Neurotrophic Factors

Scientific medicine is not easy. By this point we have largely picked the low hanging fruit, and continued improvements are mostly incremental and hard won. In order to get the most out of our limited research dollars, and optimize medical practice with the safest and most effective treatments, we need to use all available scientific evidence in the proper way. That is the essence of SBM.

There are those, however, that misuse or abuse the scientific evidence — whether to promote an ideology, out of innocent ignorance, or for nefarious purposes. In order to be truly science-based a medical intervention should be plausible, or at least not implausible, based upon basic science evidence, and it should actually be safe and effective when tested in people. Therefore, medical practices can fail to be scientific for one of two broad reasons: they can be scientifically implausible, or they can lack proper clinical evidence for safety and efficacy (or even have evidence for lack of efficacy). Some modalities (like homeopathy) fail on both counts.

The more pernicious medical claims are those that seem highly plausible, that can be extrapolated from basic science, but simply lack adequate clinical evidence. Stem cell clinics are an example — they can easily dazzle desperate patients with scientific descriptions of how stem cells work, and even cite published basic-science papers showing the potential of this technology. But what they cannot do is provide clinical evidence that the specific intervention they are offering is safe and effective for the specific disease or condition they are treating.

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Posted in: Herbs & Supplements, Neuroscience/Mental Health, Science and Medicine

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Random Flu Thoughts

I normally write the first draft of this blog the weekend before it is due, and this is no exception.  However, I am ill this weekend.  Headache, myalgias., painful cough, but only mildly ill.  The worst part is the interferon induced brain fog; my thoughts flow with all the speed of pudding and I was not appreciably better as the week progressed, although no cracks about how  you can’t any difference in my writing over baseline.

I doubt the cause of my symptoms is influenza.  According to the CDC site and Google flu trends there is little influenza activity in the US at the moment, so it is probably one of the innumerable viruses that can cause a flu-like illness.  I am also not ill enough to think I have influenza, but I could be having a modified course as I was vaccinated a month ago.  Of course, the doctor who treats herself has a fool for a patient and an idiot for a doctor. Flu season approaches, so from my interferon addled brains, flu thoughts.

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Posted in: Public Health, Science and Medicine, Vaccines

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Potential market for alternative medicine left untouched

A few days ago, I had the good fortune to share lunch and ideas with David Gorski and Kimball Atwood.  Kimball was on his way from a talk at Michigan State to one at Brigham and Women’s, one of the country’s best-known teaching hospitals.  David was planning a future talk for a group in Florida.  These guys have been thinking and writing about alternative medicine for a lot longer than I, and it was great to pick their brains, toss around ideas, and just hang out on a nice fall day.

We were discussing many of the inanities of so-called alternative medicine touted for use in “real” diseases, that is, not just symptomatic care.  There have been, for example, an number of studies out of China in the last few years claiming that acupuncture helps with in-vitro fertilization. All of these studies have been terribly flawed, and the reasons for these flaws are interesting, but irrelevant beside the primary flaw:  the ideas are so implausible as to render any conclusions invalid.   It is very difficult to understand how acupuncture in any of its forms could improve chances of conception, either in vivo or in vitro.

During our visit, Kimball brought up a rather interesting analogy:  if acupuncture could increase fertility, shouldn’t it also be able to decrease it?  We have scads of alternative treatments for the common cold, back pain, headache, multiple sclerosis, diabetes—everything, really.  Why not contraception?  After all, no one likes condoms, and the pill comes with its own baggage.  Nuva rings and IUDs are convenient, but can be annoying to use, or can cause problems in certain patients.   And almost all contraception relies solely on the woman.  The only possible contribution a man can make is condom use or vasectomy.

Where is the alternative medicine community?  They are usually pretty keen on getting involved in common medical problems.  Undesired pregnancy is a common problem.  Where are the studies on acupuncture for contraception?  Homeopathy?  Chiropractic?

How would these treatments look?  Acupuncture could perhaps stimulate the qi involved with spermatogenesis, causing a feedback inhibition, right?  Homeopathy, well, if a lot of sperm heading to the egg are the cause of pregnancy, then a little bit of sperm should do the trick I’d think.  You could even put them in a lozenge. And with vertebral subluxations able to cause all manner of medical problems, shouldn’t a good chiropractor be able to shove around a vertebra, impeding sperm production or release?  Contraception is big business.  Where are these guys?

Let me very clear that I am a traditionalist when it comes to contraception, preferring those methods that have been proven safe and effective.  I don’t give medical advice online, but I might make an exception here.

Speaking of implausible, after looking at some of Kimball’s slides, I wanted to do this just for giggles.

Common cuts of beef vs. Reflexology chart

Common cuts of beef


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CAM practitioners react to Andrew Weil’s proposal for a board certification for integrative medicine. It isn’t (all) pretty.

About a month ago, I discussed a rather disturbing development, namely the initiative by Dr. Andrew Weil to set up something he was going to call the American Board of Integrative Medicine, all for the purpose of creating a system of board certification for physicians practicing “integrative medicine” (IM), or, as I prefer to call them, physicians who like to integrate pseudoscience with their science, quackery with their medicine. Harsh? Yes. Accurate? Also yes. Unfortunately, many medical centers, both academic and community, are hopping on the IM bandwagon while more and more medical schools are “integrating” pseudoscience into their curricula. While one might expect Josephine Briggs of the National Center for Complementary and Alternative Medicine (NCCAM) to be cozy with IM, depressingly, even current director of the National Institutes of Health, Francis Collins, seems to have fallen into the trap.

As was admitted by Dr. Weil and his colleagues, this decision to create a board certification in IM was a huge about-face in that Weil had always argued that IM should be infused into all specialties of medicine. What happened, of course, is that once again marketing won out over idealism. Dr. Weil was concerned that there were lots of physicians and practitioners out there claiming to practice “integrative” medicine, many of whom had no qualifications in the field. At this point, the wag in me can’t resist pointing out that, given that IM “integrates” pseudoscience with science and that there really are no standards, scientific or otherwise, to guide IM practitioners (mainly because so much of IM is rank pseudoscience), why would this matter? The answer, again, comes down to branding and turf protection.

All of this is why seeing the reactions to Dr. Weil’s initiative from members of the “complementary and alternative medicine” (CAM) and IM community is very instructive. Fortunately, John Weeks of the Integrator Blog has come through again, quoting over twenty different people, including physicians, naturopaths, chiropractors, journalists, and other IM practitioners in an article entitled, appropriately enough, Integrator Forum: 20 Voices on Weil/U. Arizona and the American Board of Integrative Medicine. Yours truly is even mentioned (disparagingly, of course).

Uncharacteristically (for me), I’ll cut to the chase and tell you the results before I show you some of the quotes (with, of course, my own translation of what the IM-speak really means). Basically, physicians practicing IM tend to love what Dr. Weil is doing. All other practitioners (chiropractors, naturopaths, etc.) hate it. Of course, that’s not a big surprise given that Weil’s plan would in essence cut out all non-physician IM practitioners from being able to call themselves “integrative physicians” or, at the very least, to relegate them to a lower, non-board-certified rung in the practice hierarchy, which, I suspect, was the point all along. Andrew Weil wants IM to be “respectable,” and to him it will only become so if the riff-raff (i.e., non-physicians) are excluded.
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