Science and Medicine

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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.

Posted in: Politics and Regulation, Science and Medicine

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Constipation Myths and Facts

When it comes to health issues, bowels are big business. Bowel movements are part of everyday life, and we notice immediately when our routine changes. Constipation, from the Latin word constipare (“to crowd together”) is something almost everyone has some experience with. In most cases, it’s an occasional annoyance that resolves quickly. For others, particularly the elderly, constipation can be a chronic condition, significantly affecting quality of life.  Depending on the question and the sample surveyed, prevalence seems to vary widely.  It’s estimate that there are 2.5 million physician visits per year in the USA, and the costs of management are estimated at about $7.5 billion annually. It’s not a trivial issue.

One of the biggest challenges in interpreting both individual patient situations, as well as the literature overall, is understanding what’s defined as “constipation”. One person’s regular routine may be another person’s constipation. From my dialogue with patients, personal definitions seem to vary. Some panic after a single missed bowel movement, while others may be unconcerned with daily (or even less frequent) movements. What’s the optimal frequency? It depends. Infants may be 3x/day. Older children may be once daily. Adults may be daily or less frequently.  The literature generally, though not consistently, defines constipation as a delay or difficulty in bowel movements ( usually less than 3 per week) lasting two weeks. Symptoms can include infrequent, painful bowel movements, straining, and lumpy or hard stools.  When these problems last for more than three months, it’s termed chronic constipation. When constipation is accompanied by other symptoms like bloating, diarrhea, and abdominal pain, it may be termed  irritable bowel syndrome (IBS).

There are multiple causes of constipation. It may be a consequence of other illnesses (e.g., high/low thyroid, diabetes, cancer, and neurological diseases like multiple sclerosis). Drugs, both prescription and over-they-counter, can also cause constipation.  Primary or idiopathic constipation is a diagnosis of exclusion, after other causes have been ruled out.  If there are no signs of a more serious underlying condition, treatments can be considered.

Many have firmly-held opinions about their colon and their bowel movements: what’s normal, and what’s not. And there are equally strong opinions about the causes of, and solutions to, constipation. But despite the ubiquity of constipation and the firmly-held opinions on treatments, there’s a sizable chasm between practice and evidence.  This is an area with crappy (sorry) data, and it’s hard to sort out what are true treatment effects. But an absence of evidence isn’t evidence of absence, so we’re challenged to make the best decisions possible, despite a disappointing evidence base. Here are some common statements I’ve encountered, and an evidence check on their veracity. (more…)

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Alpha Brain – What’s Wrong with the Supplement Industry

There is an endless stream of supplement products on the market that are of questionable value. They tend to follow a similar pattern: put an essentially random assortment of vitamins, minerals, perhaps herbs and nutritional elements into a pill and then make whatever pseudo-health claims you want. Usually the claim is implied in the name of the product itself – sleepwell, or brainboost. The popular product Airborne fits this mold. It is essentially a multivitamin with the unfounded claim that it will prevent infection by boosting the immune system.

In the US, regulations (under DSHEA) specifically allow “structure/function” claims without any requirement for evidence to back up the claims. In other words, as long as you don’t mention a disease by name, you can make pretty much whatever claim you want. This was supposed to be good for the consumer, when in fact it is springtime for industry at the expense of the consumer. If your claims are outrageous enough the FTC can still go after you, but they are playing a game of whack-a-mole and losing.

Another pattern that is common is for a supplement product to contain specific components that are claimed to have specific benefits. Often these claims are based upon evidence – just the wrong kind of evidence. Basic science evidence is used inappropriately to support clinical claims. This strategy is more insidious, as it gives the public the sense that the product is science-based when it isn’t.


Posted in: Herbs & Supplements, Science and Medicine

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KA at U Minnesota and Michigan State

I’ll be giving a talk, “Homeopathy and Skepticism,” to skeptical students this Thursday, Oct 27, at the University of Minnesota (7:00 PM at MCB 3-120) and this Friday, Oct. 28, at Michigan State University (7:00 PM at Holmes Hall 106). Here is the abstract:

Homeopathy is an extraordinary popular delusion that has persisted for more than 200 years. It is now a mainstay of “complementary and alternative medicine” in spite of longstanding, definitive scientific refutations. It is of particular interest to skeptics because its history evokes fundamental concepts such as sympathetic magic, Ockham’s razor, and Hume’s Maxim, and major historical figures such as Oliver Wendell Holmes, Sr., and Hume himself.

Show up in Halloween costume if you like; I may do that myself.


Posted in: Science and Medicine

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Cranial Osteopathy in Dentistry

Editor’s note: Having just submitted a major grant on Friday and then having had to turn around and head to an NIH study section meeting today in Bethesda, I just didn’t have the time to produce something up to the usual standards of SBM for today. (And, being managing editor, I should know what’s up to the usual standards of SBM; what I started to write wasn’t it. Trust me on this.) Fortunately, Dr. Grant Ritchey and Dr. Steve Hendry, two skeptical, science-based dentists, did submit something up to SBM’s usual standards. Even better, since we’ve been having a number of requests for posts involving dentistry, it seemed like a perfect time to publish their first contribution to SBM and see how our readers like it. Maybe next time around, I’ll have them update the “state of knowledge” regarding amalgams.

Form follows function, as the old saying goes. Nowhere in the human body is this adage more fitting than in the oral cavity.  In less than two generations, the practice of dentistry has evolved from basic pain relief and function-based procedures (such as extractions and fillings), into today’s practices of complex cosmetic rehabilitation, orthopedic and orthodontic management of the teeth, jaws, and facial structures, replacing missing teeth with dental implants, and treatment of sleep apnea and temporomandibular joint (TMJ) disorders, to name but a few.   With such rapid progress, it is to be expected that for every science based advance made in our field, there are just as many claims that are either dubious in their evidential support or outright pseudo-scientific or anti-scientific nonsense.

In this article, we’ll be taking a look at the roles that health care practitioners such as chiropractors, osteopathic physicians, and physical therapists, are attempting to play in the dental field.  We will also see how well-meaning dentists have been trained in and apply their pseudo-scientific principles in their dental practices. In particular, we’ll be examining Cranial Osteopathy (also known as Craniosacral Therapy or Cranial Therapy) in the management of the dental patient, the purported benefits claimed by practitioners of cranial osteopathy, and the quality and quantity of evidence for this type of treatment in the scientific literature.

Posted in: Chiropractic, Dentistry, Science and Medicine

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Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.2: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont. again)

“Strong Medicine”: Ted Kaptchuk and the Powerful Placebo

At the beginning of the first edition of The Web that has no Weaver, published in 1983, author Ted Kaptchuk portended his eventual academic interest in the placebo:

A story is told in China about a peasant who had worked as a maintenance man in a newly established Western missionary hospital. When he retired to his remote home village, he took with him some hypodermic needles and lots of antibiotics. He put up a shingle, and whenever someone came to him with a fever, he injected the patient with the wonder drugs. A remarkable percentage of these people got well, despite the fact that this practitioner of Western medicine knew next to nothing about what he was doing. In the West today, much of what passes for Chinese medicine is not very different from the so-called Western medicine practiced by this Chinese peasant. Out of a complex medical system, only the bare essentials of acupuncture technique have reached the West. Patients often get well from such treatment because acupuncture, like Western antibiotics, is strong medicine.

Other than to wonder if Kaptchuk had watched too many cowboy ‘n’ Native American movies as a kid, when I first read that passage I barely blinked. Although the Chinese peasant may have occasionally treated someone infected with a bacterium susceptible to his antibiotic, most people will get well no matter what you do, because most illnesses are self-limited. Most people feel better even sooner if they think that someone with special expertise is taking care of them. If you want to call those phenomena the “placebo effect,” in the colloquial sense of the term, fine. That, I supposed, was what Kaptchuk meant by “strong medicine.”

Turns out I was mistaken. Let’s briefly follow Kaptchuk’s career path after 1983. In the 2000 edition of The Web, he wrote:


Posted in: Acupuncture, Basic Science, Book & movie reviews, Chiropractic, Clinical Trials, Homeopathy, Medical Academia, Science and Medicine

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The Prostrate Placebo

I seem to be writing a lot about the urinary tract this month. Just coincidence, I assure you. As I slide into old age, medical issues that were once only of cursory interest for a young whippersnapper have increasing potential to be directly applicable to grumpy old geezers. Like benign prostatic hypertrophy (BPH). I am heading into an age where I may have to start paying attention to my prostate (not prostrate, as it is so often pronounced, although an infection of the former certainly can make you the latter), so articles that in former days I would have ignored, I read. JAMA this month has what should be the nail in the coffin of saw palmetto, demonstrating that the herb has no efficacy in the treatment of symptoms of BPH: Effect of increasing doses of saw palmetto extract on lower urinary tract symptoms: a randomized trial.

It demonstrated that compared to placebo, saw palmetto did nothing. There have been multiple studies in the past with the more or less the usual arc of clinical studies of CAM products: better designed trials showing decreasing efficacy, until excellent studies show no effect. There is the usual meta analysis or two, where all the suboptimal studies are lumped together, the authors bemoan the quality of the data, and proceed to draw conclusions from the garbage anyway. GIGO.

The NEJM study from 2006 demonstrated that saw palmetto was no better than placebo but it was suggested that perhaps the dose of saw palmetto was not high enough or that the patients were not treated long enough to demonstrate an effect, and the JAMA study hoped to remedy that defect. (more…)

Posted in: Clinical Trials, Herbs & Supplements, Science and Medicine

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Statistical Errors in Mainstream Journals

While we frequently on SBM target the worst abuses of science in medicine, it’s important to recognize that doing rigorous science is complex and mainstream scientists often fall short of the ideal. In fact, one of the advantages of exploring pseudoscience in medicine is developing a sensitive detector for errors in logic, method, and analysis. Many of the errors we point out in so-called “alternative” medicine also crop up elsewhere in medicine – although usually to a much less degree.

It is not uncommon, for example, for a paper to fail to adjust for multiple analysis – if you compare many variables you have to take that into consideration when doing the statistical analysis otherwise the probability of a chance correlation will be increased.

I discussed just yesterday on NeuroLogica the misapplication of meta-analysis – in this case to the question of whether or not CCSVI correlates with multiple sclerosis. I find this very common in the literature, essentially a failure to appreciate the limits of this particular analysis tool.

Another example comes recently from the journal Nature Neuroscience (an article I learned about from Ben Goldacre over at the Bad Science blog). Erroneous analyses of interactions in neuroscience: a problem of significance investigates the frequency of a subtle but important statistical error in high profile neuroscience journals.


Posted in: Neuroscience/Mental Health, Science and Medicine

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