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Horses, Zebras, and the Availability Heuristic

It was a chevrotain.

It was a chevrotain. (Josh More, Flickr)

During a particularly difficult shift early in my career, I spent the better part of two hours at the bedside with a patient’s family discussing the unexpected discovery of a large tumor in their child’s brain. The implications of the finding were grave, and the family was understandably devastated. I was just a few years out of residency and this was the first time I had made such a life altering diagnosis by myself, and it was by far the hardest news I had ever had to break to a family. Needless to say it was an experience that I will never forget, and one that has influenced my approach to medicine ever since.

The diagnosis was a surprise to everyone. There were of course red flags that appropriately led to the ordering of an MRI, but I really didn’t expect it to find anything. It wasn’t based on the fear of a lawsuit or the discomfort with uncertainty, influences that dictate the practice of medicine far too often, with the latter being considerably more of a problem (in my opinion). There was enough to support embarking on an encephalic expedition, but nothing so blatant as to really raise my suspicions.  My guard was down and my emotional response to the situation was intense. Later, after care of the patient had been transferred to the pediatric oncology service, my introspective nature took over.

The sound of approaching hoofbeats

In medical school, there is an old adage often passed down to learners by seasoned physicians that serves to rein in an overly broad differential diagnosis, particularly when it includes increasingly unlikely etiologies. When one hears the sound of approaching hoofbeats, the inexperienced students are cautioned, one should expect to see horses rather than zebras. The world of medicine rarely mimics an episode of House, M.D. (more…)

Posted in: Science and Medicine

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A systematic review about nothing

Water
There is dubious content in PubMed that you won’t find unless you look for it, or stumble across it inadvertently. It’s the entire field of alternative medicine which is abstracted and complied along with the actual medical literature. In this world, the impossible is accepted as fact, and journal articles focus on the medical equivalent of counting angels on pinheads. I’ve been trying to avoid blogging about alternative medicine practices like homeopathy lately because the practice itself is a scientific dead end. There is no emerging evidence or interesting research to describe, because there is no science to build on. But research on homeopathy is interesting if one wants to understand how placebo effects can appear to be real. Importantly, research and clinical trials of homeopathy allow us to see the underlying (baseline) challenges, flaws, and biases in evaluating real medicine more clearly. Today I want to review a newly-published systematic review of, adverse effects attributed to homeopathy. The casual reader might not see the multiple problems with this type of research. But once you understand the basis of homeopathy, the conclusion that one can draw is quite different from that of the author’s. And if inert sugar pills can appear to have medicinal effects, and even adverse effects, then we can better adjust for these biases when we’re studying actual medicine. (more…)

Posted in: Clinical Trials, Homeopathy

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Australia’s New Antiscience Party

HAPIn a perfect world, high quality science would inform politics and policy. Science cannot determine policy by itself because there are also value judgments and trade-offs that need to be negotiated. At the least, however, policy should be consistent with the best available science.

We, of course, don’t live in a perfect world. Too often politics and ideology seem to inform, or corrupt, science. It is so much easier to just cherry pick the science that seems to confirm what you already believe, than to go through the process of changing your beliefs to accommodate the evidence. The stronger the ideology, the greater the motivated reasoning used to defend it, without apparent practical limit. For core ideologies that are part of someone’s identity, there does not appear to be any amount of evidence that will change their beliefs.

Anti-scientific motivated reasoning is often codified in specific organizations, institutions, or professions. Political parties are essentially organized ideologies, and when that ideology is predominantly pseudoscientific, you have organized pseudoscience. (more…)

Posted in: Politics and Regulation

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The THRIVE Experience: Masterful Marketing, Short on Substance

One of the few things that aren't in THRIVE products

One of the few things that aren’t in THRIVE products

My daughter told me about the latest health fad among her group of acquaintances. She knows people who are spending $300 a month on the THRIVE program and claiming miraculous results. With a skeptic for a mother, my daughter knew enough to question the claims and do her own research; she was not impressed. She concluded that THRIVE was essentially selling caffeine and vitamins at exorbitant prices.

Claims on the website

THRIVE is offered by Le-Vel Brands, LLC. A slick video on the website asks:

Are you ready to hear about the hottest weight loss, nutrition and fitness plan sweeping North America? It’s called the THRIVE 8-week experience. The only premium lifestyle transformation plan. People from all walks of life are accomplishing their physical goals with THRIVE, and many are also accomplishing their financial goals by choosing to promote the experience.

  • Weight management
  • Joint support
  • Pain management
  • Antioxidant support
  • Cognitive performance
  • Lean muscle support
  • Anti-aging
  • Digestive and immune support
  • Calms general discomfort

“You’re going to live, look, and feel Ultra Premium like never before.”

Testimonials: yes. Hype: yes. Evidence: no. (more…)

Posted in: Herbs & Supplements

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What’s the harm? Stem cell tourism edition

What's the harm? Stroke victim Jim Gass went from requiring a cane and leg brace to walk to being confined to a wheelchair, thanks to dubious stem cell treatments. There's the harm.

What’s the harm? Stroke victim Jim Gass went from requiring a cane and leg brace to walk to being confined to a wheelchair, thanks to dubious stem cell treatments. There’s the harm.

It’s been over two weeks now since hockey legend Gordie Howe died at the age of 88. Detroit, as I’ve pointed out elsewhere, is a serious hockey town, as hockey-crazy as any town in Canada (just look at the fancy new hockey arena named after crappy pizza being built downtown only a mile from where I work), and it worshiped Gordie Howe for as long as I can remember growing up here.

The reason I mentioned this is because in late 2014, Howe suffered a series of debilitating strokes that brought him close to death. He survived, but with major neurologic deficits. As a result of Gordie Howe’s fame, representatives of a company known as Stemedica who were also fans of Gordie Howe and whose company is developing stem cell treatments for a variety of illnesses, approached the family and persuaded them to take Gordie Howe to the Novastem Clinic in Tijuana, a clinic that to me appeared to exist mainly as a means for patients not eligible for Stemedica’s clinical trials in the US to receive Stemedica’s stem cells outside of a clinical trial, cash on the barrelhead, no questions asked. In a rather ethically dubious move that could only be viewed as paying for publicity (which it got in abundance), Stemedica administered its stem cells to Gordie Howe for free. If you’re not Gordie Howe, however, it’ll cost you about $32,000.

As is the case for most anecdotes like this, Gordie Howe did improve. That is not surprising, because, as Steve Novella, who is a neurologist and thus takes care of stroke patients as part of his practice, told me at the time, the natural history of stroke is neurologic recovery that eventually plateaus several months after the stroke. This occurs as the inflammation from the initial stroke abates and as much regeneration as the body can muster occurs. Also, as I noted before, Howe had a hemorrhagic stroke, which is more dangerous and likely to kill early but, if the victim survives, he is more likely to experience better functional recovery than in the case of the much more common ischemic stroke, in which a blood clot clogs a blood vessel, resulting in the death of brain tissue supplied by that vessel. In any case, as I described in a three part series of posts (part one, part two, part three), it’s impossible to know whether the stem cell infusion that Howe underwent had anything whatsoever with his partial recovery that allowed him to make a few public appearances in 2015 and 2016.

Unfortunately, the offer by Dr. Maynard Howe (CEO) and Dave McGuigan (VP) of Stemedica Cell Technologies to treat Gordie Howe at Novastem worked brilliantly. Gordie Howe quickly became the poster child for dubious stem cell therapies. Local and national news aired credulous, feel-good human interest stories about his seemingly miraculous recovery, while Keith Olbermann practically served as a pitch man for Stemedica and didn’t take kindly at all to any criticism of his—shall we say?—enthusiastic coverage. The predominant angle taken in stories about Gordie Howe was he had undergone Stemedica’s stem cell therapy and, as result, enjoyed a “miraculous recovery” from his stroke. The vast majority of news coverage also tended to present the magic of stem cell therapies credulously, as all benefit and no risk, as a qualitative analysis published last year clearly showed, finding that the “efficacy of stem cell treatments is often assumed in news coverage and readers’ comments” and that media coverage “that presents uncritical perspectives on unproven stem cell therapies may create patient expectations, may have an affect [sic] on policy discussions, and help to feed the marketing of unproven therapies.”

No kidding.

Why, you might ask, am I reminding you of Gordie Howe’s use of stem cells to treat his strokes? Simple, it became part of a marketing blitz, credulously swallowed whole by Keith Olbermann and many reporters, for unproven stem cell therapies, which have been portrayed as very promising (which is likely true, although that promise hasn’t yet been proven or realized) and harmless, which is definitely not true, as evidenced by the story of Jim Gass, as published last week in The New England Journal of Medicine, The New York Times, The Boston Globe, and a variety of other media. Before I discuss Mr. Gass in more detail, however, let’s recap a bit about stem cells. (more…)

Posted in: Clinical Trials, Ethics, Health Fraud, Science and the Media

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Book Review Lagniappe

bookworm
Lagniappe, a word often heard in New Orleans, refers to a bonus or extra gift, like the thirteenth donut in a baker’s dozen. You may have noticed that I write a lot of book reviews. I read far more books than I review, and I have always loved to read about the experiences of doctors and the interesting patients and intriguing illnesses they have encountered. I thought I would write an extra post this week to share some titles that SBM readers might also enjoy.

I value these books for several reasons. They are entertaining. They prove that doctors are not all evil Big Pharma shills just in it for the money. They let readers vicariously experience what it is like to be a doctor in a particular specialty or setting. They highlight the joys of helping patients, as well as the many frustrations doctors struggle with. They put a human face on the practice of medicine. (more…)

Posted in: Book & movie reviews

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Why Science-Based Medicine Matters

A child with smallpox; the cost of unscientific medicine. This is why science-based medicine matters.

A child with smallpox; the cost of unscientific medicine. This is why science-based medicine matters.

The regular contributors at Science-Based Medicine (SBM) work diligently every week to explore the world of science-based medicine and the gauzy, nebulous netherworld of fantasy-based medicine. They shine light on the leading edge of medical science, dissect the nuances of mainstream care, expose the misconceptions and sometimes the frank deceptions of so-called alternative medicine. Launching SBM on January 1, 2008, sbmadmin (Steven Novella?) described the mission of the blog as: “scientifically examin[ing] medical and health topics of interest to the public [including] reviewing newly published studies, examining dubious products and claims, providing much needed scientific balance to the often credulous health reporting, and exploring issues related to the regulation of scientific quality in medicine.” He went on to propound an elegant yet simple core philosophy that “safe and effective health care is critical to everyone’s quality of life; so much so that it is generally considered a basic human right.”

This last deserves, I think, especially careful consideration. Enshrined in the aspirational manifesto of the United States, the Declaration of Independence, is the claim for all people to inherent and inalienable rights to “Life, Liberty and the pursuit of Happiness.” And while Jefferson used the phrase in the context of personal political freedoms, health is central to the exercise of those rights. It is the role of medicine to secure health, to provide a structure and a system by which all can live life as long and as free from disease and disability as our individual circumstances allow. (more…)

Posted in: History, Science and Medicine

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About Herbs: an app to avoid

Pictured: A better source of health information than "About Herbs".

Pictured: A better source of health information than “About Herbs”.

Medicine has an intellectual hierarchy. Supposedly the best and the brightest are in the academic medical centers and are the thought leaders in their field.

Those of us lower in the hierarchy are well aware of some of the warts present on our betters, but I would expect those at the top would adhere to the highest intellectual and ethical standards. People being, well, people, expecting exceptional standards is admittedly an unrealistic expectation.

It would appear that many academic centers are doing their best to avoid meeting my expectations, attempting to abandon all standards.

I mentioned over at SfSBM that Dana-Farber is spending 2 million dollars on a renovation to, in part, offer the unmitigated steer manure that is reiki and reflexology to their cancer patients. Yes. Reiki. Reflexology.

Those are not fracking earthquakes in Kentucky, those tremors are the result of the tremendous kinetic energy of Flexner spinning in his grave as his life’s work becomes a farce.

Dana-Farber is just one of many academic medical centers who are putting their imprimatur on nonsense.

Memorial Sloan Kettering Cancer Integrative has released “About Herbs”, an iPad/iPhone guide to Botanicals, Supplements, Complementary Therapies and More. Spoiler alert: the ‘More’ does not include critical thinking. This guide is not anywhere as ludicrous as offering reeky, sorry, reiki, but at times it comes close. (more…)

Posted in: Acupuncture, Commentary, Critical Thinking, Herbs & Supplements, Homeopathy, Traditional Chinese Medicine

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The rise and inevitable fall of Vitamin D

Is Vitamin D a panacea? The evidence says otherwise.

Is vitamin D a panacea? The evidence says otherwise.

It’s been difficult to avoid the buzz about vitamin D over the past few years. While it has a  long history of use in the medical treatment of osteoporosis, a large number of observational studies have linked low vitamin D levels to a range of illnesses. The hypothesis that there is widespread deficiency in the population has led to interest in measuring vitamin D blood levels. Demand for testing has jumped as many physicians have incorporated testing into routine care. This is not just due to alternative medicine purveyors that promote vitamin D as a panacea. Much of this demand and interest has been driven by health professionals like physicians and pharmacists who have looked at what is often weak, preliminary and sometimes inconclusive data, and concluded that the benefits of vitamin D outweigh the risks. After all, it’s a vitamin, right? How much harm can vitamin D cause? (more…)

Posted in: Herbs & Supplements, Nutrition

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MEND Protocol For Alzheimer’s Disease

Post-mortem cross sections of a healthy brain (left) and a brain with advanced Alzheimer disease (right), showing characteristic shrinkage.

Post-mortem cross sections of a healthy brain (left) and a brain with advanced Alzheimer disease (right), showing characteristic shrinkage.

The medical profession is currently engaged in a simmering debate about what is the best overall approach to take toward the relationship between science and health care. I would say that the current dominant model is Evidence-Based Medicine (EBM). We, of course, advocate for a number of tweaks to EBM we call Science-Based Medicine (SBM).

SBM essentially advocates for an ironic-sounding holistic approach to scientific evidence. All evidence should be considered in its proper context with an eye toward the strengths and weaknesses of each kind of evidence, and in the context of the institutions of science and medicine. SBM represents a higher standard of overall evidence, which we feel is justified given the degree to which medical interventions are adopted prematurely (as evidenced by later reversals).

At the same time there are those, in the minority but with an established presence, who are essentially arguing for lowering the standard of science in health care. They exist on a spectrum, at one end including those who would abandon science entirely in favor of spirituality and philosophy-based medicine. At the other end are those who claim to endorse science but want to change the rules of scientific medicine to include a much lower standard of evidence. This is more pseudoscience than antiscience. Chief among them, in my opinion, are proponents of what they call “functional medicine.” Functional medicine essentially uses science incorrectly, but still cloaks itself with the imprimatur of science. (more…)

Posted in: Neuroscience/Mental Health

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