Mea culpa to the max. I completely forgot that today is my day to post on SBM, so I’m going to have to cheat a little. Here is a link to a recent article by yours truly that appeared on Virtual Mentor, an online ethics journal published by the AMA with major input from medical students. Note that I didn’t write the initial scenario; that was provided to me for my comments. The contents for the entire issue, titled “Complementary and Alternative Therapies—Medicine’s Response,” are here. Check out some of the other contributors (I was unaware of who they would be when I agreed to write my piece).
Archive for Science and Medicine
Everything you know may be wrong. Well, not really, but reading the research of John Ioannidis does make you wonder. His work, concentrated on research about research, is a popular topic here at SBM. And that’s because he’s focused on improving the way evidence is brought to bear on decision-making. His most famous papers get to the core of questioning how we know what we know (or what we assume) to be evidence. (more…)
There are a few “laws” of the blogosphere, one of them being that a response to a post that comes more than a few weeks later is generally useless or crazy. But once in a while, someone takes the time to look at an old post and formulate a thoughtful response.
This is not one of those times.
Or maybe it is. I’ll report (and editorialize), you decide.
Regarding a piece I first published in September of 2010, a reader writes:
Dear Dr. Gorski:[our managing editor]
I am writing regarding your comments on the following blog
I am not a doctor but am pursuing an MA and hopefully a PhD in nutrition and public health. I am very familiar with Dr. Fuhrman and his work. I have heard many of Dr. Fuhrman’s lectures and if anything they are all based on concrete scientific research. I must express my disappointment about both the tone and factual content of the article written. I read extensively about nutrition, exercise and their health benefits. Much of the research done in this field has been conducted in small clinical trials or in the laboratory. There is a good reason for this. Only the government has the financial ability to pay the tens of millions of dollars needed to conduct large scale clinical trials in this area since a drug company would in all probability not have any financial gain from a clinical trial showing that individuals eating 10 servings of vegetables each day have a significant reduction in chronic disease. I do feel that all epidemiological as well as clinical work done points to the very clear fact that people die years before they need to due to the poor diets they have. It is also very clear that most physicians have very little knowledge about nutrition since it is generally a very minor part of their education. I agree with doctor Fuhrman that any debate should be both science based and held to the highest ethical standards. From what I see the article written as well as your comments do not meet these standards. I find that most disconcerting due to the fact that individuals put their lives in their hands when they consult with you as a physician.
In closing I would like your comment on the follwing statement that was made by Dr. William Castelli, who ran the Framingham Study for about 20 years. An interviewer asked him what percent of heart disease could be avoided through proper nutrition and exercise. His response was very brief. 100%!! Do you agree with one of foremost reaearcers of the 20th century or do you consider him to be a quack too.
I await your response.
What is instructive here is the usual thoughtful but incorrect “reasoning” used by someone with just enough knowledge to think he understands the topic at hand well enough to rebut. The rebuttal, however, makes use of the usual fallacies that are the fallback position for the ignorant and the mendacious (and I must point out that I think our Dear Correspondent is the former).
Since I wrote the piece, not Dr. Gorski, I take full responsibility for its content and defend my writing personally. A bit of a fisking is in order to help us all better understand how to think about these questions properly.
At home the kids current TV show of choice is How I Met Your Mother, supplanting Scrubs as the veg out show in the evening. Both shows are always on a cable channel somewhere and are often broadcast late at night. Late night commercials can be curious, and as I work on projects, I watch the shows and commercials out of the corner of my eye.
Law firms trolling for business seem common. If you or a family member has had a serious stroke, heart attack or death from Avandia, call now. The non-serious deaths? I suppose do not bother. One ad in particular caught my eye: anyone who developed ulcerative colitis or Crohn’s disease (collectively referred to inflammatory bowel disease, or IBD) after using Accutane, call now. Millions have been awarded.
My eye may have been caught because of my new progressive lenses, but I will admit to an interest in inflammatory bowel disease, having had ulcerative colitis for years until I took the steel cure. It also piqued my interest as these were three conditions among which I could not seen any connections. Accutane, ulcerative colitis, and Crohn’s. One of these is not like the other.
Editor’s note: This weekend was a big grant writing weekend for me. I’m resubmitting my R01, which means that between now and July 1 or so, my life is insanity, as I try to rewrite it into a form that has a fighting chance of being in the top 7%, which is about the level the NCI is funding at right now. This weekend, I buried myself in my Sanctum Sanctorum and tried like heck to try to pound the revision into a really good draft that I can distribute to my colleagues for feedback. Fortunately, I have some old posts that I can pull out, tart up (i.e., update a bit, as in correcting the parts that led me to groan as I reread them, thereby hopefully making them better). I think they’re quite good, if I do say so myself; so hopefully you will too.
There are some arguments made in blogs, articles, or books that strike me so hard that I remember them, even three and a half years later. Sometimes I even file them away for later use or response if the issue raised by them is interesting, relevant or compelling enough to me. Although this topic is a bit broader than many of the topics I write about for this blog, I think it also goes to the heart of science-based medicine and communicating scientific skepticism about medicine to the masses. A few years back, a Swedish blogger named Martin Rundkvist made a rather provocative observation about skepticism. Specifically, he argued that a “real skeptic always sides with scientific consensus.” Among his reasons was this one:
Science presupposes that all participants have a skeptical frame of mind and arrive at conclusions through rational deliberation. If a large group of knowledgeable people working in this way arrive at a consensus opinion, then there is really no good reason for anybody with less knowledge of the subject to question it. Informed consensus is how scientific truth is established. It’s always provisional and open to reevaluation, but as long as there’s informed consensus, then that’s our best knowledge. Humanity’s best knowledge.
Although at the time I saw where Martin was coming from, I found this viewpoint somewhat disturbing, leading me to echo Martin’s own words in response to his own rhetorical question asking whether accepting a scientific consensus is nothing more than “kowtowing to white-coated authority”: Well, yes and no.
Some people have made the mistake of seeing Shunt’s work as a load of rubbish about railway timetables, but clever people like me, who talk loudly in restaurants, see this as a deliberate ambiguity, a plea for understanding in a mechanized world. The points are frozen, the beast is dead. What is the difference? What indeed is the point? The point is frozen, the beast is late out of Paddington. The point is taken. If La Fontaine’s elk would spurn Tom Jones the engine must be our head, the dining car our esophagus, the guard’s van our left lung, the cattle truck our shins, the first-class compartment the piece of skin at the nape of the neck and the level crossing an electric elk called Simon. The clarity is devastating. But where is the ambiguity? It’s over there in a box. Shunt is saying the 8:15 from Gillingham when in reality he means the 8:13 from Gillingham. The train is the same only the time is altered. Ecce homo, ergo elk. La Fontaine knew his sister and knew her bloody well. The point is taken, the beast is moulting, the fluff gets up your nose. The illusion is complete; it is reality, the reality is illusion and the ambiguity is the only truth. But is the truth, as Hitchcock observes, in the box? No there isn’t room, the ambiguity has put on weight. The point is taken, the elk is dead, the beast stops at Swindon, Chabrol stops at nothing, I’m having treatment and La Fontaine can get knotted.
— Art Critic
Ambiguity. Medicine, like art, is filled with ambiguity, at least the way I practice it. Most of my practice is in the hospital. I am sometimes called to see patients that other physicians cannot figure out. And that puts me at a disadvantage, because the doctors who were referring patients to me are all bright, excellent doctors. Often the question is ‘Why does the patient have a fever?’ or ‘Why is the patient ill?’ Sometimes I have an answer. Most of the time I do not.
I am happy, however, to be able to tell the patient what they don’t have. I can often inform the patient and their family that whatever they have is probably not life-threatening or life-damaging, just life-inconveniencing, and most acute illnesses go away with no diagnosis. I always put the ‘just’ in air quotes, because illnesses that require hospitalization are rarely ‘just.’ Just without quotes is reserved for the antivaccine crowd and applied to the small number of deaths from vaccine preventable diseases in unvaccinated children. John Donne they ain’t.
We are excellent, I tell them, at diagnosing life-threatening problems that we can treat, and terrible at diagnosing processes that are self-limited. Of course diagnostic testing is always variable. No test is 100% in making a diagnosis, and often with infections I cannot grow the organism that I suspect is causing the patient’s disease. So for hospitalized patients, ambiguity and uncertainty are the rule of the day. (more…)
The course of research into so-called alternative medicine (CAM) over the last 20 years has largely followed the same pattern. There was little research into many of the popular CAM modalities, but proponents supported them anyway. We don’t need science, they argued, because we have anecdotes, history, and intuition.
When media attention, which drove public attention, was increasingly paid to CAM then serious scientific research increased. A specific manifestation of this was the National Center for Complementary and Alternative Medicine (NCCAM). CAM proponents then argued that their modalities were legitimate because they were being studied (as if that’s enough). Just you wait until all the positive evidence comes rolling in showing how right we were all along.
But then the evidence started coming in negative. A review of the research funded by NCCAM, for example, found that 10 years and 2.5 billion dollars of research had found no proof for any CAM modality. They must be doing something wrong, Senator Harkin (the NCCAM’s major backer) complained. They engaged in a bit of the kettle defense – they argue that the evidence is positive (by cherry picking, usually preliminary evidence), but when it is pointed out to them that evidence is actually negative they argue that the studies were not done fairly. But then when they are allowed to have studies done their way, but still well-controlled, and they are still negative, they argue that “Western science cannot test my CAM modalities.”
It is hard to get infected. The immune system is robust and has a multitude of interlinking defenses that are extremely efficient in beating off most pathogens. Most of the time.
Fortunately, it is a minority of microbes that have evolved to be virulent in humans. Bacteremia is common with our own microbiome. When you brush or floss, bacteria leak into the blood stream:
We identified oral bacterial species in blood cultures following single-tooth extraction and tooth brushing. Sequence analysis of 16S rRNA genes identified 98 different bacterial species recovered from 151 bacteremic subjects. Of interest, 48 of the isolates represented 19 novel species of Prevotella, Fusobacterium, Streptococcus, Actinomyces, Capnocytophaga, Selenomonas, and Veillonella.
but with a good immune system, low virulence bacteria and no place to go, unfortunately the bacteria rarely cause infections.
Even heroin users rarely get infection. Heroin is a rich melange of with bacteria and, on occasion, yeasts (I hate to say contaminated, since avoiding microbes is hardly a worry of heroin manufacturers), and the water used for injection is rarely sterile, yet infections are relatively rare despite the filth in which many heroin users exist.
I used to be somewhat fatalistic about hospital acquired infections. However, as the institutions in which I have worked have proven, almost all infections in the hospital are preventable if the institutions aggressively pursue high standards of care.
There are many systems in place in society to prevent infections: flush toilets, good nutrition, public health, vaccines, antibiotics, good hygiene, and an understanding of disease epidemiology, and I suspect people forget there are bugs out there that are pathogenic, just waiting to sicken and kill us. At least a couple of times a year I see patients come into the hospital, previously healthy, who rapidly die of acute infections. But for most people, most of the time, it takes a lot of effort to get an infection.
From my perspective we are Charlie Chaplain on skates , mostly unaware of the infections that awaits us if we do something silly, or even when we act with the best intentions to avoid illness. The odds are small we will get a life threatening or serious infection in the US, just as the odds are small we will drown or be killed in a car accident. The germs are there, waiting, and in the end, no matter what we do, we will be consumed by the microbial world. (more…)
Whether it’s acupuncture, homeopathy or the latest supplement, placebo effects can be difficult to distinguish from real effects. Today’s post sets aside the challenge of identifying placebo effects and look at how placebos are used in routine medical practice. I’ve been a pharmacist for almost 20 years, and have never seen a placebo in practice, where the patient was actively deceived by the physician and the pharmacist. So I was quite surprised to see some placebo usage figures cited by Tom Blackwell, writing in the National Post last week:
The practice is discouraged by major medical groups, considered unethical by many doctors and with uncertain benefit, but one in five Canadian physicians prescribes or hands out some kind of placebo to their often-unknowing patients, a new study suggests.
The article references a paper in the Canadian Journal of Psychiatry which, sadly, does not have much of a web presence. The article continues:
In my recent review of Peter Palmieri’s book Suffer the Children I said I would later try to cover some of the many other important issues he brings up. One of the themes in the book is the process of critical thinking and the various cognitive traps doctors fall into. I will address some of them here. This is not meant to be systematic or comprehensive, but rather a miscellany of things to think about. Some of these overlap.
Everything is attributed to a pet diagnosis. Palmieri gives the example of a colleague of his who thinks everything from septic shock to behavior disorders are due to low levels of HDL, which he treats with high doses of niacin. There is a tendency to widen the criteria so that any collection of symptoms can be seen as evidence of the condition. If the hole is big enough, pegs of any shape will fit through. Some doctors attribute everything to food allergies, depression, environmental sensitivities, hormone imbalances, and other favorite diagnoses. CAM is notorious for claiming to have found the one true cause of all disease (subluxations, an imbalance of qi, etc.).