In part 2 of the Science-Based Medicine 101 series we take a look at the second pillar of good science: plausibility. This blog post was written for a lay audience so more advanced readers will need to indulge me here…
I really enjoy sci-fi action movies. I love the convincing special effects and the fact that heroes can accomplish the physically impossible without skipping a beat. Implausible events unfurl with convincing reality, and you never know what might happen with the plot.
I also enjoy the TV show, America’s Funniest Home Videos, for different reasons. The mundane nature of actual reality, and the often predictable, but hilarious mistakes made by those I relate to result in some pretty hearty laughs.
But there is a big difference between these two forms of entertainment: science-fiction requires the suspension of belief in plausibility, while home videos are based on plausible outcomes. When it comes to medical research, though, plausibility can mean the difference between science fiction and reality.
It is my contention that terms such as “complementary and alternative medicine” and “integrative medicine” exist for two primary purposes. The first is marketing – they are an attempt at rebranding methods that do not meet the usual standards of unqualified “medicine”. The second is a very deliberate and often calculating attempt at creating a double standard.
We already have a standard of care within medicine, and although its application is imperfect its principles are clear – the best available scientific evidence should be used to determine that medical interventions meet a minimum standard of safety and effectiveness. Regulations have largely (although also imperfectly) reflected that principle, as have academia, publishing standards, professional organizations, licensing boards, and product regulation.
With the creation of the new brand of medicine (CAM and integrative) came the opportunity to change the rules of science and medicine to create an alternative standard, one tailor made for those modalities that do not meet existing scientific and even ethical standards for medicine. This manifests in many ways – the NCCAM was created so that these modalities would have an alternate standard for garnering federal dollars for research. Many states now have “health care freedom laws” which create a separate standard of care (actually an elimination of the standard of care) for self-proclaimed “alternative” practices.
Chiropractic originated in 1895 when D.D. Palmer claimed to have restored deaf janitor Harvey Lillard’s hearing by manipulating his spine. This makes no anatomical sense, and few if any chiropractors claim to be able to reverse deafness today. But now a chiropractic website is attempting to vindicate D. D. Palmer. They list deafness among a long (wrong) list of “Conditions That Respond Well to Chiropractic”
They list 6 supporting studies. Three are case reports, two are case series, and one is a review of the literature that is labeled in its title as “A Search to Validate” D.D. Palmer. (more…)
One thing I always encourage my residents and students to do is to go to primary sources. If someone tells you that thiazide diruetics should be the first line treatment for hypertension, get on MedLine and see if that assertion is congruent with the evidence. It’s important to see how we arrive at broad treatment recommendations, how strong and consistent the evidence is, and the best way to do this is go back to the beginning.
This is not an explicitly political blog, and for that reason, I don’t feel it’s appropriate for me to advocate for one or another proposed health care reform plan. But I do want to encourage everyone to follow health care reform closely, and to go to the primary sources. Certain aspects of the proposed bill will be hard for any of us to understand, especially cost. There are all sorts of wild claims about how much reform will save us or cost us, and I’m betting that none of these claims is completely congruent with the truth. But some of what we’re hearing on the news is so far from the truth that to call them lies would be generous. (more…)
If there’s one thing we emphasize here on the Science-Based Medicine blog, it’s that the best medical care is based on science. In other words, we are far more for science-based medicine, than we are against against so-called “complementary and alternative medicine” (CAM). My perspective on the issue is that treatments not based on science need to be either subjected to scientific scrutiny if they have sufficient prior plausibility or strong clinical data suggesting efficacy or abandoned if they do not.
Unfortunately, even though the proportion of medical therapies not based on science is far lower than CAM advocates would like you to believe, there are still more treatments in “conventional” medicine that are insufficiently based on science or that have never been validated by proper randomized clinical trials than we as practitioners of science-based medicine would like. This is true for some because there are simply too few patients with a given disease; i.e., the disease is rare. Indeed, for some diseases, there will never be a definitive trial because they are just too uncommon. For others, it’s because of what I like to call medical fads, whereby a treatment appears effective anecdotally or in small uncontrolled trials and, due to the bandwagon effect, becomes widely adopted. Sometimes there is a financial incentive for such treatments to persist; sometimes it’s habit. Indeed, there’s an old saying that, for a treatment truly to disappear, the older generation of physicians has to retire or die off.
That is why I consider it worthwhile to write about a treatment that appears to be on the way to disappearing. At least, I hope that’s what’s going on. It’s also a cautionary tale about how the very same sorts of factors, such as placebo effects, reliance on anecdotal evidence, and regression to the mean, can bedevil those of us dedicated to SBM just as much as it does the investigation of CAM. It should serve as a warning to those of us who might feel a bit too smug about just how dedicated to SBM modern medicine is. Given that the technique in question is an invasive (although not a surgical technique), I also feel that it is my duty as the resident surgeon on SBM to tackle this topic. On the other hand, this case also demonstrates how SBM is, like the science upon which it is based, self-correcting. The question is: What will physicians do with the most recent information from very recently reported clinical trials that clearly show a very favored and lucrative treatment does not work better than a placebo?
Here’s the story that illustrates these issues, fresh from the New York Times this week:
One month ago, I was honored to take part not just in the Science-Based Medicine Conference at TAM 7 in Las Vegas but to be a part of the Anti-Anti-Vax Panel. I was even more honored to be on the same panel as Dr. Joe Albietz, a pediatric intensivist from the University of Colorado who organized a fund-raising drive to benefit the Southern Nevada Health District and contribute to the vaccination of children in a region where the vaccination rate is, unfortunately, low. I’m even more pleased that Dr. Albietz has agreed to join SBM as a regular blogger. Here’s a little bit about Joe:
Joseph Albietz, M.D. is an Assistant Professor of Pediatrics at the University of Colorado, Denver, and The Children’s Hospital. In addition to his service in the Pediatric Intensive Care Unit, his time is divided between translational research in the field of pediatric pulmonary hypertension and medical education where he acts as the pediatric intensive care associate fellowship director. Dr. Albietz graduated from the University of Missouri at Kansas City and completed his residency training in pediatrics and a fellowship in pediatric critical care at the University of Colorado, Denver. He is board certified in Pediatrics and Pediatric Critical Care.
In addition to writing for Science Based Medicine Dr. Albietz also periodically contributes to the James Randi Educational Foundation’s (JREF) Swift Blog and coordinated JREF’s vaccine drive to benefit the Southern Nevada Health District.
Dr. Albietz’s first blog post is scheduled for Friday, August 21. In the meantime, please welcome him to the fold. He’s a great addition to our crew of bloggers.
EDITOR’S NOTE: Dr. Atwood, who would normally be scheduled to post today, is on vacation. Consequently, we are publishing the following guest post by Samuel Homola, D.C., a retired chiropractor who limited his practice to science-based methods and spoke out against the irrational and abusive practices of his colleagues. He is the author of Inside Chiropractic and Bonesetting, Chiropractic, and Cultism and co-author with Stephen Barrett of the skeptical Chirobase website, a division of Quackwatch) .
In 1895, Daniel David Palmer, a magnetic healer, announced that “95 percent of diseases are caused by displaced vertebrae; the remainder by luxations of other joints.” He opened the first chiropractic school in Davenport, Iowa—the Palmer Infirmary, which offered a three-week course of instruction.
In 1906, D.D. Palmer’s son, Bartlett Joshua Palmer, a 1902 graduate of the Palmer Infirmary, took over his father’s school. In 1924, claiming that “subluxation” of any vertebra would cause disease by compressing nerves in the intervertebral foramina, B.J. Palmer introduced the “Neurocalometer,” a thermocouple device guaranteed to locate nerve-pinching vertebral subluxations. Chiropractors were told that if they did not use this “infallible” device to measure heat differentials on the skin over the spine, they could not competently locate and adjust a subluxation. But the Neurocalometer was not for sale. Chiropractors were forced to lease the instrument and then pay a monthly rent.
In the early 1930s, after nearly three decades of teaching that subluxations anywhere in the spine can cause disease, B.J. Palmer announced that he had found the one and only cause of disease: subluxation of the atlas. Palmer concluded that subluxation of a spinal vertebra below the axis was not possible because vertebrae below that level were bound together by intervertebral discs and interlocking joints. Students at the Palmer School of Chiropractic were not permitted to adjust the spine below the axis until 1949 when full-spine techniques were once again included in the course of instruction.
B.J. Palmer’s “hole-in-one” (HIO) technique for adjusting the atlas and the axis remained popular among certain factions of the chiropractic profession. According to the 2005 edition of Job Analysis of Chiropractic, published by the National Board of Chiropractic Examines, 25.7% of practicing chiropractors include the “Palmer upper cervical/HIO” technique in their adjustive procedures. (more…)
Let’s look at one example.
A unknown number of Functional Medicine adherents broadcast call-in programs on radio stations. One FM physician, a Dr. “D” in Northern California graduated from UC Davis School of Medicine (Central California’s Sacramento Valley.) I find her program fascinating, requiring some attentive listening.
Dr. D’s recommendations for people’s complaints and conditions are often complex, a chimera of standard explanations and therapies, but painted with a variety of views that are anything but standard. The problem I found was that some of each answer was rational – especially the logic of her differential diagnosis – but suddenly spun out into space with unfamiliar methods or some recognizable as one component or another of sectarianism. Some answers had no relationship to the problem at hand, but seemed to be plucked out of a firmament of independent ideas, theories, ideologies, and personal anecdotes – a medical Separate Reality.
One can be carried along by an answer that sounds on surface reasonable because of the confidence and the delivery’s vocal tone. Her voice is medium-low, sort of a mezzo or contralto. It’s a voice ideal for advice; confidence oozes. Some of her separate reality recommendations she precedes with a biochemical or physiological explanation, so the shifting from standard to “separate reality” grids goes so smoothly, the usual recognizable red flags may not spring up.
Reuters recently reported on the raid of a stem-cell clinic in Hungary. This is welcome news, if the allegations are correct, but really is only scratching the surface of this problem – clinics offering dubious stem cell therapies to desperate patients. And in fact this is only one manifestation of a far greater problem – the quack clinic. They represent a serious problem for patients, doctors, and health care regulation.
Stem Cell Clinics
There is a very disturbing trend in the last few years – the proliferation of clinics offering stem cell therapy for a variety of serious, often incurable, diseases such as spinal cord injury, ALS, Parkinson’s disease, and other neurological disorders. These clinics claim to improve and even cure these diseases by injecting stem cells into the spinal cord or other parts of the body. Treatments typically cost 20-25,000 dollars, plus travel expenses, for a single treatment.
The problem is that these clinics do not have any published evidence that their treatments are valid. There is good reason to think that they are not – stem cell technology is simply not at the point yet where we can use them to cure such diseases. There are many technical hurdles to be overcome first – knowing how to control the stem cells, to get them to survive and become the types of cells necessary to have the desired therapeutic effect, and also figuring out how to keep them from growing into tumors. Basic issues of safety have not yet been sorted out.