There is something in molecular biology and genetics known as the “central dogma.” I must admit, I’ve always hated the use of the word “dogma” associated with science, but no less a luminary than Francis Crick first stated it in 1958, and it has been restated over the years in various ways. Perhaps my favorite version of the central dogma was succinctly stated by Marshall Nirenberg, who said, “DNA makes RNA makes protein,” which about sums up all of molecular biology in five words. Or at least it did until the last ten or twenty years, when we’ve been finding exceptions to this dogma.
I don’t want to dwell on the central dogma. As I’ve said, I loathe the use of the term “dogma” to describe anything in science, although a discussion of the central dogma and its exceptions might make for a decent post one day. What brought the central dogma to mind is a series of articles I saw recently in ONCOLOGY: Perspectives on Best Practices that let me to ponder the question: What is the “central dogma” of “alternative medicine”? I realize that alt-med is an unwieldy gmish of ideas that range from the semi-plausible but unproven to the completely ridiculous (i.e., homeopathy or reiki), but after reading these articles and thinking about it, I do believe that there is in actuality a “central dogma” of alternative medicine. I also believe that it is entirely appropriate to call it a “dogma” in this situation, because it is far more a matter of faith than it is of science. Moreover, the more that quackademic medicine infiltrates academic medicine, the more this “central dogma” has infiltrated academic medicine with it. Indeed, as you will see, when this central dogma is questioned, even by someone sympathetic to “complementary and alternative medicine” (CAM; i.e., “complementing” medicine with quackery) or “integrative medicine” (i.e., the “integration” of pseudoscientific medicine with medicine).
I do not want to get all angsty and omphaloskeptic, but I have been thinking more of late about the purpose of the blog and my role in it. Blogs,and the people who write them, are ephemeral. It takes a unique personality and commitment to churn out these essays and commit them to the ether. Especially since Michelson and Morley.
I have never given much thought as to who our readers are, at least as a composite. I read most of the comments on every entry and have certainly developed a mental picture of some of our regular commenters, although I suspect I probably do not have even the gender correct most of the time. The commenters represent a tiny fraction of the regular readers and an even smaller fraction of occasional readers. It occurs to me I haven’t a clue who the real audience of this blog is.
I write first for my own education and entertainment, then for the slightly bored and overwhelmed medicine resident, since that is who I spend most of my time educating at work. Someone educated with an understanding of basic medicine but has more important things on their mind than a need for a detailed understanding of why homeopathy is complete nonsense. I doubt the majority of my readers are health care workers and I suspect continuing medical education is not a major part of the blog.
I never considered SBM to be a consumer protection group, but this week my wife showed me a half page advertisement in the local paper, and I realized that not only was the advertisement a good topic for blogging, but consumer protection is a fundamental result of this blog. There really is no site on the interweb that looks at both SCAM and real medicine with quite the same skeptical eye. Here is the headline:
A Special Wellness Report
New Medicine Based On An 88- Year Old Theory By Albert Einstein Can Help Almost Everyone Who Is Sick Or Injured! (more…)
The burgeoning U.S. stem cell therapy industry was delivered a setback last month in the form of a U.S. District Court injunction against use of the “Regenexx™ Procedure,” which purports to treat joint, muscle, tendon or bone pain due to injury or other conditions. The court agreed with the FDA that the cell product used in the procedure is both a drug and a “biological product” subject to FDA regulation. Because a similar process is used in other stem cell therapies the decision increases the possibility that the FDA will take a like position in other cases.
The general term “stem cell therapy” comprises an array of treatments which range from the clinically proven to quackery. On one end of the spectrum is blood stem cell transplantation to treat diseases and conditions of the blood and immune system. On the other lies the kind of stem cell therapy tourism addressed by both Steve Novella (here and here) and Orac (here and here), which involves the injection of what may, or may not be, stem cells from what may, or may not be, humans. In between fall therapies which are plausible and have promise but have not been adequately tested in clinical trials. There is a concern that these therapies are being oversold by clinics which charge thousands of dollars (not reimbursed by insurance) to treat conditions including multiple sclerosis, musculoskeletal pain, and cardiac disease.
There is a tradition in medical training called Journal Club. The first rule of Journal Club is you do not talk about Journal Club. In Journal Club, at least in the iterations in which I have participated, one article is selected by an attending, everyone reads it, then the strengths, weakness and applicability are discussed by the group. Usually a top notch, ground breaking article was the focus, one that had high potential clinical impact. But since they were good articles in good journals, there was not a lot to learn about in reguards to critical thinking. While the attending would put the article in context and maybe discuss some rudimentary statistics, there was little that was discussed about the quality of the study. The main take home from every study was to question the applicability of the results to populations that were not old, white males, since it seemed all the ground breaking studies back in the day were a VA Cooperative study of one sort or another.
As I remember it, there was not really a conceptual frame work with which to evaluate studies. Bayes theorem, and its application to clinical medicine was never explicitly discussed outside of testing, where you have to consider the prior plausibility of the patient having a disease before you can decide if the test results is a true positive or not. In Portland, Oregon, the chance that a Lyme serology is a false positive is much greater than a test done in Portland, Maine. Generally speaking in the information overload state that is the practice of medicine, clinical trials are generally taken at face value and tests are considered infallible. Which is a shame, as I wonder how much suboptimal medicine is inflicted on patients by not considering prior plausibility and how accurate a given test is in either ruling in or out a disease. There seems to be a whole industry built around treating patients with no risks for Lyme but have positive tests of doubtful provenance. We never discussed the prior plausibility and its effect on the outcomes of a studied treatment. (more…)
Summer time is finally here in Oregon, and I will confess that I have spent little time on blogging. The sun is out, my kids are out of school and home from college, and really, who wants to spend their time writing when you could be on the golf course or at the beach with the kids. I say this as a mea culpa for what follows.
One of the saving graces in medicine is just how hard it is to harm people and how much trauma humans can withstand and survive. When I am on call for my partner I cover a Level 1 trauma ICU and the hallway leading to the unit is lined with photographs of some the trauma survivors. Over the years I have helped take care of many of these patients and I remember the extent of the injuries and the intensity of the care required to pull them through. Most of the survivors are young; it is the young who have the physiologic reserve to deal with the stress of injuries and their consequences.
Still, human physiology is amazingly resilient, especially of there are no co-morbid conditions to interfere with healing. With a little, and sometimes a lot, of support, I am constantly amazed at what people can sometimes survive. Modern medicine can pull people through who would have certainlu died 20 years ago.
There are two way to hurt people: what you do and what you do not do, the harms of commission and omission. Harm can be obvious with surgery. Oops, sorry I left my watch in there. I definitely do not have what it takes to be a surgeon. Or you can prescribe a medicine with a known side effect. Most SCAM’s, by doing nothing, are not prone to this sort of harm. Chiropractic and acupuncture are the notable exceptions, but even then it is hard to tear a vertebral artery or drop a lung unless the patient is extraordinarily unlucky. Of course one of the things you learn in medicine is that occasionally someone is extraordinarily unlucky and has a rare, but not unexpected, complication of an intervention, SCAM or otherwise. (more…)
Practitioners of so-called “complementary and alternative medicine” currently enjoy a certain measure of government largesse in the form of state laws mandating coverage of their services by private health insurance plans. The federal Patient Protection and Affordable Care Act (often referred to as the Affordable Care Act, or “ACA,” and sometimes as “Obamacare”) has the potential of putting a significant dent in this forced coverage of pseudoscientific health care.
All states require private health insurers to cover certain health care services by law. These mandates can be in the form of requirements that specific health care services or treatments be covered, that certain providers be covered, or that certain populations be covered.
Mandates are ubiquitous, inconsistent among states and costly. One insurance industry trade group calculates that there are currently 2,262 separate state mandates. Some are supported by clear evidence of benefit, such as immunizations and mammograms. Others, unfortunately, require coverage of “CAM” services, such as acupuncture and chiropractic. (In fact, acupuncture is typically not covered by small group plans unless required by state mandate.) Whether beneficial or not, all agree that these mandates increase premium costs to the consumer, most estimated to be from less than one percent to five percent of premiums, depending on the mandate. Chiropractic coverage, for example, can vary from state to state, from limiting the insured to a specific number of visits per year all the way to requiring chiropractors to be covered on par with medical doctors.
One of the common claims of alternative medicine practitioners is that they individualize their treatment while conventional medicine treats all patients the same. This is nonsense on several levels, but it is also a common excuse for why randomized clinical trials cannot be performed, or cannot be viewed as reliable evidence, in evaluating some alternative therapies. However, some trials have been done that attempt to account for this supposed individualization of therapy, and generally they have failed to show a benefit to the supposedly individualized approach. One of those, involving Traditional Chinese Medicine (TCM) was recently discussed by Edzard Ernst, one of few, and most productive researchers in the CAM field applying an evidence-based approach:
Matthias Lechner, MD, Iva Steirer, MD, Benno Brinkhaus, MD, Yun Chen, CMD, Claudia Krist-Dungl, MS, Alexandra Koschier, MS, Martina Gantschacher, MA, Kurt Neumann, MS, and Andrea Zauner-Dungl, MD. Efficacy of Individualized Chinese Herbal Medication in Osteoarthrosis of Hip and Knee: A Double-Blind,Randomized-Controlled Clinical Study. The Journal of Alternative and Complementary Medicine. 2011;17(6): 539–547.
As I have mentioned in the past, almost all of my practice is inpatient medicine, doing infectious disease consults in acute care hospitals. I only spend three hours a week in the outpatient clinic, so I have a skewed perception of medicine and disease. The patients I see are sick, really sick, often trying to die and are a complicated collection of abnormal labs and deranged physiology.
I remember finishing residency thinking that a potassium of 2.8, a hemoglobin of 9.8 or a bilirubin of 4.5 wasn’t all that bad, losing track of normal physiology amongst all the medical pathology. I never did lose track of normal vital signs (VS): pulse, respiration, blood pressure and temperature. Like trying to be the fifth Beatle, over the years other values have vied to become the fifth vital sign: pain level or O2 saturation, but none have the importance of the fab four. I can live without pain*, but I can’t live long if the other vital signs are abnormal for extended periods of time. Watching the vital signs return to normal is often an important variable that signifies the patient is improving. (more…)
As a group blog, Science-Based Medicine brings a variety of perspectives to issues of science in medicine. However we align around a few core principles which define what science-based medicine is, and how it should be practiced. One principle we emphasize is the importance of subjecting the evaluation of all health interventions and treatments to a single, science-based standard. One of the biggest successes of the alternative medicine industry, worldwide, has been the embedding of different regulatory standards for the evaluation and approval of so-called “non-drug” products such as supplements, herbal products, and non-scientific treatment systems like homeopathy or traditional Chinese medicine (TCM). The implications cannot be overstated: this different and lower standard is now so firmly entrenched in most health systems that few seem to question its rationale, or consider the consequences. As a practicing pharmacist I spent the first decade of my career working within this regulatory framework without ever stepping back to question why we regulate some products differently. I started reading, took the red pill, and here I am today. (more…)
I wrote previously about bee venom therapy (BVT), also called apitherapy or bee sting therapy, as an emerging “alternative” therapy. Both use and research into BVT continue, providing an excellent example of the many things that are wrong with the CAM movement.
A recent Reuters article on the topic is also an excellent example of the frequent complete failure of the mainstream media in dealing with such topics. The articles discusses a Filipino bee keeper who decided to practice medicine based upon his personal anecdotal experience. Joel Magsaysay suffered a stroke and right-sided weakness. He attributes his recovery from the stroke partly to bee stings.
He admits he is not a physician and has no medical or scientific background. He has concluded that BVT works based upon anecdote along. He seems to be unaware of the unreliability of individual anecdotes in stroke recovery. Most patients will improve following a stroke. There are also two kinds of recovery, including neurological recovery from brain plasticity.