I recently wrote an article for a community newspaper attempting to explain to scientifically naive readers why testimonial “evidence” is unreliable; unfortunately, they decided not to print it. I considered using it here, but I thought it was too elementary for this audience. I have changed my mind and I am offering it below (with apologies to the majority of our readers), because it seems a few of our readers still don’t “get” why we have to use rigorous science to evaluate claims. People can be fooled, folks. All people. That includes me and it includes you. Richard Feynman said
The first principle is that you must not fool yourself–and you are the easiest person to fool.
Science is the only way to correct for our errors of perception and of attribution. It is the only way to make sure we are not fooling ourselves. Either Science-Based Medicine has not done a good job of explaining these vital facts, or some of our readers are unable or unwilling to understand our explanations.
Our commenters still frequently offer testimonials about how some CAM method “really worked for me.” They fail to understand that they have no basis for claiming that it “worked.” All they can really claim is that they observed an improvement following the treatment. That could indicate a real effect or it could indicate an inaccurate observation or it could indicate a post hoc ergo propter hoc error, a false assumption that temporal correlation meant causation. Such observations are only a starting point: we need to do science to find out what the observations mean. (more…)
I don’t recall if I’ve mentioned it on SBM before, but I went to the University of Michigan. In fact, I didn’t go there just for undergraduate studies or medical school, but rather for both, graduating with a B.S. in Chemistry with Honors in 1984 and from medical school in 1988. In my eight years in Ann Arbor, I came to love the place, and I still have an affinity for it, even though it’s been over 20 years since I last walked about the campus as a student, although I have been back from time to time for various functions, most recently to see Brian Deer speak last winter. True, I’m not fanatical about it, as some of my contemporaries and friends who attened U. of M. with me back in the 1980s (and, sadly, the string of losses to Ohio State and the definitively mediocre last season Michigan had last year make it very hard to be a Michigan football fan these days). However, I do have considerable affection for the place. It molded me, trained me in science, taught me medicine, and provided me the basis for everything I do professionally today.
First some background. I was first directed to the Marshall protocol by a reader who wondered about the information the found on the web. So I went to the web and looked at the available information, much as any patient would, and discussed what I found there.
I have subsequently been lead to believe that none of the information on the website http://www.marshallprotocol.com can be considered up to date or accurate. As as result of, I have told that my post is chockablock with errors, although, outside of writing doxycycline where I should have put minocycline, I am left in the dark as to exactly what my errors are. I am told that it is my responsibility to locate the errors in the last post, yet I can find none when compared to the website.
However, to remedy the deficiency of having reviewed inaccurate and out of date material, I have been sent 6 articles that I am informed represent the state of the art in understanding the science behind the Marshall protocol. Ah, the peer reviewed medical literature. An opportunity to carefully read and critique new ideas. It is one of the reasons people publish: to see if their ideas can withstand the scrutiny of others.
Several of these papers concern Vitamin D, the Vitamin D receptor, and olmesartan which I will review, perhaps, another time. I don’t find them a compelling read, but it not an area about which I have more than a standard medical knowledge. The other papers concern the role of infection in autoimmune diseases, which I will discuss here. It is easier as an infectious disease doctor to read this literature as I am, as least as far as the American Board on Internal Medicine is concerned, a specialist in the field. Alternatively, I am a closed minded tool of the medical industrial complex who only seeks to push his own twisted, narrow agenda at the expense of suffering patients (1). We can’t all be perfect.
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…)