The recent albuterol vs. placebo trial reported in the New England Journal of Medicine (NEJM) found that experimental subjects with asthma experienced substantial, measured improvements in lung function after inhaling albuterol, but not after inhaling placebo, undergoing sham acupuncture, or “no treatment.” It also found that the same subjects reported having felt substantially improved after either albuterol or each of the two sham treatments, but not after “no treatment.” Anthropologist Daniel Moerman, in an accompanying editorial, wrote, “the authors conclude that the patient reports were ‘unreliable,’ since they reported improvement when there was none”—precisely as any rational clinician or biomedical scientist would have concluded.
In Part 1 of this blog we saw that Moerman took issue with that conclusion. He argued, with just a bit of hedging, that the subjects’ perceptions of improvement were more important than objective measures of their lung function. I wondered how the NEJM editors had chosen someone whose bibliography predicted such an anti-medical opinion. I doubted that Editor-in-Chief Jeffrey Drazen, an expert in the pathophysiology of asthma, had ever heard of Moerman. I suggested, in a way that probably appeared facetious, that Ted Kaptchuk, the senior author of the asthma report, might have recommended him. (more…)
Acupuncture, Chiropractic, Clinical Trials, Health Fraud, Herbs & Supplements, History, Medical Academia, Medical Ethics, Naturopathy, Pharmaceuticals, Science and Medicine, Science and the Media
Online discussions on the merits of alternative medicine can get quite heated. And its proponents, given enough time, will inevitably cite the same drug as “evidence” of the failings of science. Call it Gavura’s Law, with apologies to Mike Godwin:
As an online discussion on the effectiveness of alternative medicine grows longer, the probability that thalidomide will be cited approaches one.
A recent comment on my own blog, regarding the homeopathic product Traumeel, is typical:
If the scientific method is all that separates an accepted claim, ie Thalidomide, Vioxx, Bextra, Darvon, from mere anecdote, of what benefit is the Science?
As a non-scientist consumer, I’ll take the anecdotes and my own experience. Thank you.
If scientists want to be taken seriously, they must stop selling themselves to the highest bidder becoming corporate whores without a shred of decency. To my mind, that’s how the claims for Thalidomide, Vioxx, Bextra, Darvon were accepted, making the scientific method utterly worthless.
To this commenter, “science has been wrong before.” And that invalidates science, and apparently validates homeopathy. It’s a fallacious argument. But does thalidomide actually represent a failing of science-based medicine? No, not even close. It’s so wrong, it’s not even wrong. Thalidomide is good example of the importance of science-based medicine and why allowing alternative medicine to be sold in the absence of good science is a concern. (more…)
There have been many cases now of big companies or organizations, or wealthy individuals, threatening to sue or actually suing a blogger for libel. The most famous case is that of Simon Singh who was sued by the British Chiropractic Association over comments he made in an article. Simon braved through the expensive and exhaustive legal process (which is especially onerous in England), but he is not just a lone blogger. He is a successful author and was writing for the Guardian. Eventually the BCA was forced to drop the case – but only after the blogging community rallied behind Simon, magnifying his criticisms of the BCA by orders of magnitude. By all accounts it was a PR disaster.
The blogging community as a whole is rather passionate about this issue. We exist on the premise of free and open public discourse about important issues. At SBM we take on many controversial issues and we don’t pull our punches when criticizing what we see as pseudoscience in medicine. So of course we take notice when a large company tries to bully a blogger to silence their legitimate criticism.
According to the BMJ this has happened yet again – this time the international homeopathy producer, Boiron, is threatening a lone Italian blogger because he dared to criticize their product, Oscillococcinum. The blogger, Samuele Riva, wrote two articles on his blog, blogzero.it, criticizing what our own Mark Crislip has called “oh-so-silly-coccinum.” The blog is entirely in Italian, but he is maintaining a page in English with updates on the Boiron vs Blogzero affair.
Common warts (verruca vulgaris) are more of a nuisance than a serious health problem, but they are interesting. There is a whole mythology surrounding their cause (touching toads?) and treatment (everything from banana peels to vitamin C). Many people believe they can be made to vanish by suggestion or hypnosis. I used to believe that too.
Every doctor has wart stories. Here are some of mine.
- A patient made an appointment to see me because he had a wart, but when he tried to show me his wart he discovered that it had vanished! Apparently, just making the appointment cured it.
- Another patient did have obvious warts and I prescribed the “wart medicine” that our pharmacy tech compounded, based on salicylic acid. He was out of one of the ingredients and had to ask my patient to return in a week. When she returned, her warts were already gone. The wart medicine apparently worked so well that you didn’t even have to use it!
- I worked with a dermatologist who used a colorful laminated card with a picture of a toad to stroke children’s warts, telling them it was a wart remover. In his experience, this would frequently make the wart vanish over the next few days. Was this ethical? Was he lying and deliberately deceiving patients, or could this be excused as playing make-believe to distract the child and improve his attitude about the wart?
Author’s note: This post was inspired in part by a post by Wally Sampson entitled Why would medical schools associate with quackery? Or, How we did it.
Once upon a time, there was quackery.
Long ago, back in the mists of time before many of our current readers were even born and far back in the memory of even our wizened elders of medicine, “quackery” was the preferred term used to refer to ineffective and potentially harmful medical practices not supported by evidence. Physicians, having a grounding in science and prior plausibility, for the most part understood that modalities such as homeopathy, reflexology, and various “energy healing” (i.e., faith healing) methodologies were based either on prescientific vitalism, magical thinking, and/or science that was at best incorrect or at the very least grossly distorted. More importantly, physicians weren’t afraid to call quackery quackery, quacks quacks, and charlatans charlatans.
Not surprisingly, quacks and charlatans did not like this.
Summertime and the living is busy. Finally we have sun in the Northwest. While the rest of the country has been melting in heat, this year we have rarely cracked 85. Global heating has avoided Oregon this year, and I will need some green tomato recipes. Good weather, work is busy, and it is the last two weeks with my eldest before he is off to Syracuse, so there is little time for writing, so a brief entry this week.
I always wince at the way anything can be called ‘therapy.’ We have music therapy and garden therapy and pet therapy and art therapy. I do not deny that it is beneficial for people to participate in those activities while in the hospital, although I am never happy to see disease vectors, er, animals in a hospital. Dinner should be food therapy, reading should be book therapy, and using the internet should be computer therapy. I guess it is like calling something ‘medical’ grade, and you can bill more for it.
Some ‘therapies’ are a wee bit more odd. Indonesians are using railroad therapy. People lie down on electric railroad tracks because “the electricity current from the track could cure various diseases.” To date no one has been either electrocuted or squashed, but I suppose it is only a matter of time.
I have as much of a sense of nostalgia as anyone. I love history. I think that there is lots to be said about the “good old days,” whenever the heck they were. I do not, however, think that the “good old days” generally include medicine.
The fact is that it’s only been about 100 or so years since medical practitioners really got their acts together and started to be able to figure out if they were actually doing anything good. Prior to that, medicine was a world of humo(u)rs and miasms, treated by bleeding, burning, and purging, plants and animal matter of all sorts (the 6th century Chinese apparently liked otter feces) and all sorts of other awfulness. In light of some of the things that were done, it’s kind of amazing that anyone survived their treatments. Mostly, people (and horses) survived in spite of the crazy things that were done to them.
Nevertheless, in those wild and wooly days of yesteryear, enterprising medical entrepreneurs turned out an endless stream of products, with some pretty fantastic claims. They designed some absolutely artistic advertising cards to go along with those claims, too. These trade cards surged onto the scene in the 1870’s, coinciding with the advent of color printing.
In 1994 Congress (pushed by Senators Harkin and Hatch) passed DSHEA (the Dietary Supplement Health and Education Act). As regular readers of SBM know, we are not generally happy about this law, which essentially deregulated the supplement industry. Under DSHEA supplements, a category which specifically was defined to include herbals, are regulated more like food than like medicinals.
Since then the flood-gates opened, and there has been open competition in the marketplace for supplement products. This has not resulted, I would argue, in better products – only in slicker and more deceptive claims. What research we have into popular herbals and supplements shows that they are generally worthless (except for targeted vitamin supplementation, which was already part of science-based medicine, and remains so).
A company can essentially put a random combination of plants and vitamins into a pill or liquid and then make whatever health claims they wish for their product, as long as they stay within the “structure-function” guidelines. This means they cannot claim to cure or treat a specific disease, but this has proven to be an insignificant limitation on marketing supplements.
A correspondent asked me to review the book What to Expect When You’re Expecting by Heidi Murkoff and Sharon Mazel. She wrote “I’m very worried about this book.”
She had just seen an NPR article about the book and was alarmed because it provided an excerpt from the book recommending that patients with morning sickness “Try Sea-Bands” and “Go CAM Crazy.” She knew from reading SBM and other science blogs that “going CAM crazy” is not a good idea. She was savvy enough to search Google Books with the title and “CAM” and found more alarming advice. (more…)
About three weeks ago, ironically enough, right around the time of TAM 9, the New England Journal of Medicine (NEJM) inadvertently provided us in the form of a new study on asthma and placebo effects not only material for our discussion panel on placebo effects but material for multiple posts, including one by me, one by Kimball Atwood, and one by Peter Lipson, the latter two of whom tried to point out that the sorts of uses of these results could result in patients dying. Meanwhile, Mark Crislip, in his ever-inimitable fashion, discussed the study as well, using it to liken complementary and alternative medicine (CAM) as the “beer goggles of medicine,” a line I totally plan on stealing. The study itself, we all agreed, was actually pretty well done. What it showed is that in asthma a patient’s subjective assessment of how well he’s doing is a poor guide to how well his lungs are actually doing from an objective, functional standpoint. For the most part, the authors came to this conclusion as well, although their hedging and hawing over their results made almost palpable their disappointment that their chosen placebos utterly failed to produce anything resembling an objective response improving lung function as measured by changes (or lack thereof) in FEV1.
In actuality, where most of our criticism landed, and landed hard—deservedly, in my opinion—was on the accompanying editorial, written by Dr. Daniel Moerman, an emeritus professor of anthropology at the University of Michigan-Dearborn. There was a time when I thought that anthropologists might have a lot to tell us about how we practice medicine, and maybe they actually do. Unfortunately, my opinion in this matter has been considerably soured by much of what I’ve read when anthropologists try to dabble in medicine. Recently, I became aware that Moerman appeared on the Clinical Conversations podcast around the time his editorial was published, and, even though the podcast is less than 18 minutes long, Moerman’s appearance in the podcast provides a rich vein of material to mine regarding what, exactly, placebo effects are or are not, not to mention evidence that Dr. Moerman appears to like to make like Humpty-Dumpty in this passage: