Science isn’t the only game in town. Literature can teach us things about the world that science can’t. It can give us vicarious experience and insight into other minds. Two recently published novels illuminate why perfectly rational people might reject the help of scientific medicine and prefer to die a little sooner but to die on their own terms. (more…)
Editor’s note: Three members of the SBM blogging crew had a…very interesting meeting on Friday, one none of us expected, the details of which will be reported later this week–meaning you’d better keep reading this week if you want to find out. (Hint, hint.) However, what that means is that I was away Thursday and Friday; between the trip and the various family gatherings I didn’t have time for one of my usual 4,000 word screeds of fresh material. However, there is something I’ve been meaning to discuss on SBM, and it’s perfect for SBM. Fortunately, I did write something about it elsewhere three years ago. This seems like the perfect time to spiff it up, update it, and republish it. In doing so, I found myself writing far more than I had expected, making it a lot more different from the old post than I had expected, but I guess that’s just me.
In the meantime, the hunt for new bloggers goes on, with some promising results. If we haven’t gotten back to you yet (namely most of you), please be patient. This meeting and the holiday–not to mention my real life job–have interfered with that, too.
The continuum of surgical research in science-based medicine
One of the things about science-based medicine that makes it so fascinating is that it encompasses such a wide variety of modalities that it takes a similarly wide variety of science and scientific techniques to investigate various diseases. Some medical disciplines consist of mainly of problems that are relatively straightforward to study. Don’t get me wrong, though. By “straightforward,” I don’t mean that they’re easy, simply that the experimental design of a clinical trial to test a treatment is fairly easily encompassed by the paradigm of randomized clinical trials. Medical oncology is just one example, where new drugs can be tested in randomized, double-blinded trials against or in addition to the standard of care without having to account for many difficulties that arise from difficulties blinding. We’ve discussed such difficulties before, for instance, in the context of constructing adequate placebos for acupuncture trials. Indeed, this topic is critical to the application of science-based medicine to various “complementary and alternative medicine” modalities, which do not as easily lend themselves to randomized double-blind placebo-controlled trials, although I would hasten to point out that, just because it can be very difficult to do such trials is not an excuse for not doing them. The development of various “sham acupuncture” controls, one of which consisted even of just twirling a toothpick gently poked onto the skin, shows that.
One area of medicine where it is difficult to construct randomized controlled trials is surgery. The reasons are multiple. For one thing, it’s virtually impossible to blind the person doing the surgery to what he or she is doing. One way around that would be to have the surgeons who do the operations not be involved with the postoperative care of the patients at all, while the postoperative team doesn’t know which operation the patient actually got. However, most surgeons would consider this not only undesirable, but downright unethical. At least, I would. Another problem comes when the surgeries are sufficiently different that it is impossible to hide from the patient which operation he got. Moreover, surgery itself has a powerful placebo effect, as has been shown time and time again. Even so, surgical trials are very important and produce important results. For instance, I wrote about two trials for vertebral kyphoplasty for ostoporotic fractures, both of which produced negative results showing kyphoplasty to be no better than placebo. Some surgical trials have been critical to defining a science-based approach to how we treat patients, such as trials showing that survival rates are the same in breast cancer treated with lumpectomy and radiation therapy as they are when the treatment is mastectomy. Still, surgery is a set of disciplines where applying science-based medicine is arguably not as straightforward as it is in many specialties. At times, applying science-based medicine to it can be nearly as difficult as it is to do for various CAM modalities, mainly because of the difficulties in blinding. That’s why I’m always fascinated by strategies by which we as surgeons try to make our discipline more science-based.
You may recall that Steve has been criticizing a certain homeopath named John Benneth for his incredible flights of–shall we say?–fancy used in defending homeopathy. As a result, Mr. Benneth (whose website is called The Science of Homeopathy) has produced a series of amazing videos that he’s posted on YouTube. Although we have a very serious mission here at SBM, we are not without a sense of humor, and that’s why we thought our readers might be interested in the sorts of commentary we have received in response to some of our efforts. The first video is called HOMEOPATHY: Jew of Nazi Medicine:
Note how Benneth likens the criticism of his pseudoscience to the persecution of Jews by the Nazis. When you see something like this, you know that Godwin’s Law has been thoroughly invoked. The second video is just as outrageous and probably NSFW given that it drops the N-word. Don’t play it if that offends you. You have been warned:
Joseph Mercola, D.O. should be well known to readers of SBM for reflexively opposing science-based medicine while providing an endless stream of misinformation on his blog, advocating detoxification, homeopathy, the tapping of meridians chiropractic and more at his clinic, and peddling a treasure trove of vitamin supplements, foods, and Mercola-endorsed devices (on sale at his site for your convenience, no conflict of interest there!).
Nothing seems to personify the evil of modern medicine to Dr Mercola more than the concept of vaccination, and Gardasil, the vaccine against human papillomavirus (HPV), has been drawing a good deal of his ire of late. Case in point is this train-wreck of a post comparing the recent Toyota recall to Gardasil entitled “Time for the Truth About Gardasil.” The post is ill-named.
Cervical cancer accounts for less than 1 percent of all cancer deaths — so it was somewhat surprising when the U.S. Food and Drug Administration fast-tracked approval of Gardasil, a Merck vaccine targeting the human papilloma virus that causes the disease. (more…)
For a number of reasons, well-argued many times here on SBM, it would be beneficial to American citizens if the National Center for Complementary and Alternative Medicine (NCCAM) were abolished. This does not seem to be in the cards anytime soon. Here, then, are my suggestions for making the Center less dangerous and less of a marketing tool for pseudomedicine than it has been since its inception. Some suggestions might even make the Center somewhat useful. They are listed in order of priority. The Center should:
1. Abandon all unethical trials, beginning with the Trial to Assess Chelation Therapy (TACT, which is under the joint auspices of the NHLBI). This should be done in a very public manner. The reasons for abandoning the TACT, in summary, are as follows.
Happy April Fool’s Day everyone. Here’s a cartoon that I made a few years back… Enjoy!
It has been known for decades that dietary sodium is significantly associated with hypertension and coronary heart disease. Despite this knowledge, Americans continue to consume more sodium, most of it coming from processed foods. Various approaches have been used to help individuals modify their behavior, one of the most popular of which is the DASH diet. Given what we know, you would think that a low-sodium diet would be especially popular with “alternative” practitioners. After all, what could be more “natural” than lifestyle modification (a mainstay of real medicine since…well…forever).
But as any clinician knows, it’s much easier to get someone to take something than to eliminate something. Lifestyle modification is difficult, but achievable to a degree as experience has shown with cholesterol, smoking, and other modifiable risk factors. A recent study in the New England Journal of Medicine evaluated what the possible effect would be of lowering U.S. sodium consumption to 3g/day. The authors found that, “Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target.”
A new study published in PLOS Biology looks at the potential magnitude and effect of publication bias in animal trials. Essentially, the authors conclude that there is a significant file-drawer effect – failure to publish negative studies – with animal studies and this impacts the translation of animal research to human clinical trials.
SBM is greatly concerned with the technology of medical science. On one level, the methods of individual studies need to be closely analyzed for rigor and bias. But we also go to great pains to dispel the myth that individual studies can tell us much about the practice of medicine.
Reliable conclusions come from interpreting the literature as a whole, and not just individual studies. Further, the whole of the literature is greater than the sum of individual studies – there are patterns and effects in the literature itself that need to be considered.
A panels of bloggers from SBM will be taking part in the Northeast Conference on Science and Skepticism – NECSS 2010, April 17th beginning 10:00AM in New York.
There will be a 70 minute panel discussion moderated by John Snyder and featuring David Gorski, Kimball Atwood, Val Jones, and myself – Steven Novella. The topic of discussion will be the infiltration of pseudoscience into academic medicine.
This will be part of a full day of science featuring other excellent speakers, including James Randi, D. J. Grothe, Steve Mirsky, George Hrab, and Julia Galef. There will also be a live recording of the wildly popular science podcast, The Skeptics’ Guide to the Universe.
Go to www.NECSScon.org to register.
Anticoagulation is advised for patients who have had a blood clot or who are at increased risk of blood clots because of atrial fibrillation, artificial heart valves, or other conditions. Over 30 million prescriptions are written every year in the US for the anticoagulant warfarin, best known under the brand name Coumadin. Originally developed as a rat poison, warfarin has proved very effective in preventing blood clots and saving lives; but too much anticoagulation leads to the opposite problem: bleeding. A high level of Coumadin might prevent a stroke from a blood clot only to cause a stroke from an intracranial bleed. The effect varies from person to person and from day to day depending on things like the amount of vitamin K in the diet and interactions with other medications. It requires careful monitoring with blood tests, and it is tricky because there is a delay between changing the dose and seeing the results.
In his book The Language of Life, Francis Collins predicts that Coumadin will be the first drug for which the so-called Dx-Rx paradigm — a genetic test (Dx) followed by a prescription (Rx) — will enter mainstream medical practice. FDA economists have estimated that by formally integrating genetic testing into routine warfarin therapy, the US alone would avoid 85,000 serious bleeding events and 17,000 strokes annually.
A recent news release from the American College of Cardiology described a paper at their annual meeting reporting a study of
896 people who, shortly after beginning warfarin therapy, gave a blood sample or cheek swab that was analyzed for expression of two genes — CYP2C9 and VKORC1 — that revealed sensitivity to warfarin. People with high sensitivity were put on a reduced dose of warfarin and had frequent blood tests. People with low sensitivity were given a higher dose of warfarin.
During the first six months that they took warfarin, those who underwent genetic testing were 31 percent less likely to be hospitalized for any reason and 29 percent less likely to be hospitalized for bleeding or thromboembolism than were a group that did not have genetic testing.
Epstein said that the cost of the genetic testing — $250 to $400 — would be justified by reduced hospitalization costs.
At this point, I don’t believe this study. I’ll explain why I’m skeptical. (more…)