Science-based medicine is, among other things, a tool. Science helps us sequester our biases so that we may better understand reality. Of course, there is no way to avoid being human; our biases and our intuition still betray us, and when they do, we use other tools. Ethics help us think through situations using an explicitly-stated set of values that most of us agree upon (and in order to get wide agreement, these precepts must be pretty general).
Ethical problems are a normal part of medical practice. In medical school I received a bit of formal didactic education on ethics, and on the floors we often have formal ethical discussions to help understand and resolve conflicts. But ethics are not a weapon used to obtain a result we want; they are a tool to give a framework for understanding and resolving dilemmas. Ethical dilemmas can arise out of may types of conflicts, for example when our personal beliefs clash with those of our patients, or when patients’ and families’ desires conflict. They can also arise when we as physicians are constrained in our actions by outside forces.
On SBM we have documented the many and various ways that science is abused in the pursuit of health (or making money from those who are pursuing health). One such method is to take a new, but reasonable, scientific hypothesis and run with it, long past the current state of the evidence. We see this with the many bogus stem cell therapy clinics that are popping up in parts of the world with lax regulation.
This type of medical pseudoscience is particularly challenging to deal with, because there is a scientific paper trail that seems to support many of the claims of proponents. The claims themselves may have significant plausibility, and parts of the claims may in fact be true. Efforts to educate the public about such treatments are frustrated by the mainstream media’s lazy tendency to discuss every study as if it were the definitive last word on a topic, and to site individual experts as if they represent the consensus of scientific opinion.
Recent claims made for low dose naltrexone (LDN) fit nicely into this model – a medical intervention with interesting research, but in a preliminary phase that does not justify clinical use. And yet proponents talk about it as if it is a medical revolution.
Last week I wrote about the CME presentations at an obesity course put on by the American Society of Bariatric Physicians. I saved the most controversial one for last. Dr. Kendall Gerdes is a former president of the American Academy of Environmental Medicine, which I have previously written about. The AAEM is not recognized by the American Board of Medical Specialties and is categorized by Quackwatch as a questionable organization. Dr. Gerdes spoke on food allergies and food addiction.
I wasn’t convinced: I thought much of what he said was questionable. I thought, as a challenge for our readers, it might be an interesting exercise to present his information without comment and let readers look for flaws and form their own opinions. At the end, I’ll offer some suggestions of things to think about.
He described the concept of food addiction as a powerful tool to free patients from compulsive eating. Patients may “have the experience of” being addicted to foods or have symptoms of hunger and of just not feeling well. Specific symptoms of food addiction include fatigue, fibromyalgia, GI symptoms, cardiac arrhythmias, asthma, rhinitis, arthritis and seizures. There is no “gold standard” way to diagnose food allergies. He relies mainly on avoidance and challenge. (more…)
In a paper published in 2008, two academic chiropractors offered this observation: “The health claims made by chiropractors with respect to the application of manipulation as a health care intervention for pediatric health conditions continue to be supported by only low levels of scientific evidence. Chiropractors continue to treat a wide variety of pediatric health conditions.”1
Despite lack of support by the medical and scientific community, chiropractic treatment of children is growing in popularity, and more chiropractors are specializing in “chiropractic pediatrics.”
The International Chiropractic Association offers a post-graduate “Diplomate in Clinical Chiropractic Pediatrics” (DICCP) and publishes a “peer reviewed” Journal of Clinical Chiropractic Pediatrics. The diplomate syllabus is a 30-module, 360+ hours classroom course during weekends over a three-year period. There is no hospital training and no contact with diseased or injured children — only a “mandatory observational/training weekend at a chiropractic center for special needs children under multi-disciplinary care.”2 A post-graduate certification in chiropractic pediatrics (CICCP) can be earned after 180 hours of classroom instruction.
In a June 2008 joint press release, the American Chiropractic Association’s (ACA) Council on Chiropractic Pediatrics and the Council on Chiropractic Pediatrics of the International Chiropractors Association (ICA) announced that the ICA’s Diplomate in Clinical Chiropractic Pediatrics (DICCP) is now recognized by the ACA and its council as the official credential for specialization in chiropractic pediatrics.3
Noting increasing public support for chiropractic treatment of children, a January 2009 press release from the American Chiropractic Association made this announcement: “Survey data indicates that the percentage of chiropractic patients under 17 years of age has increased at least 8.5 percent since 1991.…Studies are beginning to show that chiropractic can help children not only with typical back and neck pain complaints, but also with issues as varied as asthma, chronic ear infections, nursing difficulties, colic and bedwetting.”4
A trend toward greater utilization of chiropractic by children has not gone unnoticed by the medical profession. An article in the January 2007 issue of Pediatrics (the official journal of the American Academy of Pediatrics) described chiropractic as the most common complementary and alternative medicine practice used by children, who made an estimated 30 million visits to US chiropractors in 1997.5 In 1998, children and adolescents constituted 11% of patient visits to chiropractors.6
There is a trend in the media when presenting a contentious topic to provide balance. For topics not founded upon objective facts this serves the media well; provide both sides of the argument, and let the viewer decide. The problem is that not every issue is evenly balanced, particularly in science. Covering the discovery of a new extra-solar planet by giving equal airtime to astronomers and astrologers, for example, would be the height of absurdity, yet this is precisely how the media approaches scientific topics with frightening regularity. You need look no further than the coverage of evolution, or 2012, or global climate change (that list should derail the comments nicely) for excellent examples of the same type of false balance in mainstream media outlets.
It was with trepidation, then, that I waited to see how PBS’s Frontline handled the topic of vaccination. I was pleasantly surprised. “The Vaccine War” introduced the most common concerns expressed about vaccination, and then presented the evidence addressing each concern in turn clearly and concisely. It gave airtime to some rather prominent anti-vaccine personalities, but the bulk of the program was dedicated to the data, the science, the evidence, and where answers are available it did not hesitate to present them baldly and clearly. “The Vaccine War” was not a comprehensive review of every perspective, every theory, every vaccine and study, but it did provide a fair discussion balanced by the science.
My first clue that Frontline had acquitted itself well was when Dr. Jay Gordon, pediatrician to Jenny McCarthy’s son, tweeted his opinion of the show:
PBS show about vaccines. Don’t bother to watch it.” (more…)
A few years ago a friend asked me to comment on advice given to her adult daughter by a psychiatrist whom she’d consulted for depression. The psychiatrist had recommended testing samples of saliva and urine for hormone and neurotransmitter levels, the results of which would likely indicate a need for supplements to correct deficiencies or imbalances. According to the psychiatrist, who had an academic appointment at a medical school in New York City, “I have been using these supplements with a great deal of success.” My friend is not medically or scientifically sophisticated, but this made her a little uncomfortable. In that, she was entirely justified.
During our recent panel discussion at the NECSS, a member of the audience identified himself as a clinical pathologist at a major medical center, and wondered what he might do to become involved in the good fight against encroaching pseudoscience in medical schools. Clinical pathology is the medical specialty that concerns itself, in summary, with laboratory tests—their development, their validity, their interpretation, their usefulness and, by implication, their misuse. A topic that we haven’t much featured on SBM (we touched upon it here, here and here, and probably elsewhere) is that of bogus laboratory or other diagnostic tests.
Early in my own education in modern quackery, I found it particularly distasteful not merely that quacks misuse laboratory tests, but that several commercial laboratories market misleading tests. To the untrained eye these laboratories appear to be legitimate, even to the point of their being approved by apparently legitimate certifying bodies. We’ll discuss that below, but first let’s look more closely at the psychiatrist’s recommendations to my friend’s daughter and at other examples of bogus tests.
On Tuesday night PBS FRONTLINE aired an episode about the anti-vaccine movement entitled The Vaccine War (which, by the time you read this, should be available for online viewing in case you missed it). When I first heard that this show was going to air, I was a bit concerned. My concern, of course is what I’m always concerned about when journalists do a story about pseudoscience, be it the anti-vaccine movement, “intelligent design” creationism, various “alternative medicine” modalities, or whatever. We’ve written about such things right here on SBM on more than one occasion, be it Dr. Jay Gordon on The Doctors or Andrew Wakefield being interviewed by Matt Lauer. Although FRONTLINE has done a pretty good, science-based job on controversial topics, I felt some trepidation, particularly after seeing some of the promos for the show, even though it featured Dr. Paul Offit, and other physicians and scientists.
Fortunately, I needn’t have worried. The Vaccine War is not perfect. There are some definite flaws, but by and large it is a rare thing on TV: A science-based discussion of a pseudoscientific movement. True, the opening montage did bring back a bit of that anxiety that this was going to be a “tell both sides” bit of false balance in that it included J.B. Handley blathering and Jenny McCarthy spewing her same false dilemma of measles versus autism. (She’d choose the measles, of course.) I was able to forgive that, because it’s very clear that the producers were just setting up the story. The show then launched straight into a birth and a list of the vaccines that children get, with Melinda Wharton of the CDC and Paul Offit pointing out how much good vaccines do, how we no longer see diseases that once killed thousands or even milions.
Those with an anti-vaccine ideology come from various starting points. There are those who just hate vaccines – because they don’t trust the system, they don’t like the idea of injecting something into their children, or they blame vaccines for their child’s illness or disorder. There is also the “mercury militia” – those who blame environmental mercury for all ills, and whose attention was drawn to vaccines through the mercury-based thimerosal connection. I wrote recently about another group – radical environmentalists who see vaccines and just another environmental exposure the government is trying to cover up.
There is another group that has been around for a while but about which I have not written before – some elements of the right-to-life group. What is their connection to vaccines? – the false belief that vaccines contain cells from aborted fetuses. Recently Lifenews published an article with the following headline: Study Suggests Link Between Autism and Use of Cells From Abortions in Vaccines. The study, of course, does nothing of the sort.
The EPA Study
LifeNews editor, Steven Ertelt, was referring to a recent EPA study published in Environmental Science Technology called Timing of Increased Autistic Disorder Cumulative Incidence. If you read the paper you will find no mention of vaccines, let alone fetal cells in vaccines. The study simply looked at databases of autism diagnosis to see if there was a point at which the increasing cumulative diagnoses was most sharp – any turning points in the data. The point of this exercise is to suggest where to look for a potential environment factor contributing to autism – because that’s what the EPA does, look for environmental exposures that are causing human disease.
The American Society of Bariatric Physicians recently invited me to speak at their continuing medical education (CME) conference on obesity in Seattle. They got my name from Stephen Barrett of Quackwatch and asked if I could speak about questionable weight loss treatments like HGH, MIC (methionine, inositol and choline), and the HCG Diet. I seized the opportunity to discuss how to evaluate any medical claim, with examples from alternative medicine as well as from weight loss. My title was “Questionable Evidence for Questionable Treatments.” I talked about some of the things that can go wrong in clinical trials and why simply finding reports of positive randomized controlled trials (RCT) is not enough. I advocated rigorously science-based medicine and recommended the SBM website.
Several people came up afterwards to express their thanks and their agreement, but some of the questions from the audience were rather hostile. One man said he was a military doctor and he was using and teaching acupuncture (which I had criticized as a bad example of “tooth fairy science” in my talk). I asked for his opinion of battlefield acupuncture and he just said “No comment.” A couple of people thought science wasn’t enough and thought it was okay to prescribe questionable treatments when there was no proven effective treatment. I responded that I had no objection as long as the patient was told the facts and not given the false impression that the questionable treatment had been tested and shown to work.
I was glad for the chance to meet some of the ASBP members. I had never met a bariatric physician and was interested to learn about their practices and philosophies. I had never really thought about the fact that most obese patients had associated diseases like hypertension and diabetes, so their overall management could be very complex. I attended the whole obesity course: some of what I heard was educational, some of it was questionable, and some of it was frankly disturbing. (more…)
Last week I participated in a panel discussion at NECSS with John Snyder, Kimball Atwood, and Steve Novella, who reported on the conference last Monday. What I mentioned to some of the attendees is that I had managed to combine NECSS with a yearly ritual that I seldom miss, namely the yearly meeting of the American Association for Cancer Research (AACR) meeting. There are two huge cancer meetings every year, AACR and the annual meeting of the American Society for Clinical Oncology (ASCO). AACR is the meeting dedicated to basic and translational research; ASCO, as the word “clinical” in its name implies, is devoted mainly to clinical research. Personally, being a translational researcher myself and a surgeon, I tend to prefer the AACR meeting over ASCO, not because ASCO isn’t valuable, but mainly because ASCO tends to be devoted mostly to medical oncology and chemotherapy, which are not what I do as a surgeon. Each meeting draws between 10,000 to 15,000 or even more clinicians and researchers dedicated to the eradication of cancer.
Having taken the Acela train from the NECSS meeting in New York straight to Washington, DC for the AACR meeting, I couldn’t help but think a bit about the juxtaposition of our discussion of the infiltration of quackademic medicine into medical academia with the hard core science being discussed at AACR. One session in particular at AACR highlighted what is one of the most significant differences between science-based medicine and the various forms of “alternative” medicine that we discuss here on SBM on such a regular basis. That difference, quite simply put, is the difference between the simple and the complex. “Alternative” medicine supporters often scoff at practitioners of science-based oncology, asking why we don’t have a “cure for cancer” yet—as if cancer were a single disease!—or why we haven’t made much more progress since President Richard Nixon declared “war on cancer” back in 1971. One part of the answer is that cancer is incredibly complicated. Not only is it not a single disease, but each variety of cancer is in and of itself incredibly complicated as well. To steal from Douglas Adams, cancer is complicated. You just won’t believe how vastly, hugely, mind-bogglingly complicated it is. I mean, you may think algebra is complicated, but that’s just peanuts to cancer.