Nothing says opportunistic like selling water for pain control.
The first principle is that you must not fool yourself — and you are the easiest person to fool.
I like to think of myself as a rational person, but I’ve been fooled by my own experience again and again. I’ve made bad decisions and wasted time and money believing what I was seeing, instead of being objective and looking at the evidence. One of my most memorable lessons has come over the past 14 years with my Labrador Retriever, Casey.
First the personal
We acquired Casey as a puppy, and she was less than a year old when she started limping. Investigations confirmed dysplasia, a genetic condition that leads to degenerative joints, arthritis, and pain. We were devastated. After considering the few treatment options that existed, we decided to skip surgery and treat it conservatively. I had no desire to start her on a lifetime of anti-inflammatory drugs, being very familiar with their side effect profile. I was familiar with a supplement used widely in humans that had some weak but somewhat promising evidence: We started giving her glucosamine and chondroitin supplements regularly. And we watched and waited.
It took some time, but Casey did appear to improve. We were thrilled. Life went on, and other than the occasional rough play session, Casey’s limping was mild, and she thrived. We continued the supplements, confident that we were doing good. But eventually I started paying attention to the emerging evidence on glucosamine and chondroitin. Once touted as a panacea for arthritis and joint pain, there had finally been some high-quality trials conducted – and the results were disappointing. Even this blog covered the issue, and contributors like Harriet were skeptical of glucosamine. Its supposed mechanism of action really wasn’t even that plausible. I started to wonder if the supplements were really doing anything for my dog’s pain. Eventually I decided on a trial – so I stopped the supplements about seven years after I started them. Neither my wife nor I could notice any difference at all in her mobility. Nor did the veterinarian. We’d been fooling ourselves, spending hundreds of dollars in the process. (more…)
David Lee Roth. Quality Guru.
Medicine is constantly changing, and like most health professionals, I am required to maintain my competency to practice. I doubt pharmacists are unique in being inundated with offers of continuing medical/pharmacy education. Some courses are free, some cost hundreds of dollars, and it can be difficult to distinguish the high-quality programs from the biased or low-quality education that furthers a agenda, rather than seeking to truly educate. You can consider the reputation of the provider, or the author, and sometimes the sponsorship gives a clue. When it comes to determining if a program’s content is science-based or not, I find the learning objectives may be all I need to read. One program I saw recently referred to “integrative” approaches to the treatment of an illness. Another claimed it would teach you a “holistic” approach to managing complex medical condition. Both programs set off skeptical alarm bells. I realized then I’d found the science-based medicine equivalent of a brown M&M. And I have the band Van Halen to thank for that association. (more…)
Sometimes medicine is a little like this.
I often get called on to be a diagnostician. The referring doctor is uncertain what is going on in the patient, often a fever of unknown origin, and they call me to help figure it out. Sometimes I do, sometimes I don’t.
Making the correct diagnosis is not easy, even after 35 years. The classic phrase is the fog of war, but the fog of medicine is equally confusing. In retrospect sometimes a diagnosis becomes clearer, but in real time? It is so easy to be wrong and so difficult to be correct.
I remember the first case of my career. A patient developed neutropenia (low white count) from a sulfa antibiotic and over the next two weeks went into multi-organ system failure and died. At autopsy it was discovered that he had miliary tuberculosis. I totally missed the diagnosis, despite all the tests, including liver and bone marrow biopsies before he died.
A decade later a case was presented at conference about a patient with a fever who went into multi-organ system failure and died. At the time of the conference I had zero recollection of the case from a decade earlier, but knew this was a case of miliary TB based on the data presented, although it was far from a textbook case. After the conference the presenter let me know that it had been my case, the one I had missed years ago.
I was ten years wiser in my medical career and more aware of the subtleties and variations of disease presentation. Experience has made me a somewhat better diagnostician. Or so I hope. Making the diagnosis of a common presentation of a common disease should be simple, but patients rarely read the textbooks and we are more likely to see an uncommon presentation of a common disease, a common presentation of an uncommon disease, and most dreaded, an uncommon presentation of an uncommon disease. (more…)
Pictured: Smarter than you.
For every complex problem, there is an answer that is clear, simple—and wrong.
– H.L. Mencken
Despite my multiple personalities, it seems that only the OCD doctor gets anything done. The Goth cowgirl persona? Lazy. And the NBA playoffs are sucking up an inordinate amount of time. Go Blazers. Just not very far. Sigh. But what are you going to do. Work needs doing and someone has to do it.
This week was one of deadlines. In June I am giving a series of talks at the SMACC conference in Chicago and I have to have all my talks ready to go today. So sometimes to meet all my deadlines I need to re-purpose other material.
Spoiler alert: if you are going to be at SMACC and hear my lectures, stop reading here. Everything I am going say in 6 weeks will follow. And really even if you are going to SMACC, it is a content-free post. You might be better off spending your time elsewhere. (more…)
There are few aspects of daily existence, particularly in modern society, that are more pervasive than advice on what we should eat. Everyone, including friends, family, strangers on Twitter and self-proclaimed experts in nutrition and health, seems to have an opinion on how to eat in order to improve and prolong our lives. Even legitimate organizations dedicated to the health and well-being of the population add to the cacophony of recommendations on diet.
Readers of Science-Based Medicine should be well aware of the current popularity of avoiding gluten, even absent the diagnosis of celiac disease or thoughtful evaluation for another related condition. Gluten, we are told by gurus and authors of books like Wheat Belly and Grain Brain, is the one true cause of a host of medical complaints, even autism. Avoid gluten at all costs, they say, and watch the pounds melt away or experience the clearing of your “brain fog.” (more…)
Robert Todd Carroll, the author of The Skeptic’s Dictionary, has a new book out: The Critical Thinker’s Dictionary: Biases, Fallacies, and Illusion and what you can do about them. Since some of our commenters and most of the CAM advocates we critique are constantly committing logical fallacies, a survey of logical fallacies is a good idea both for us and for them, and this book fits the bill.
When I received the book in the mail, I set it aside, thinking it would be a somewhat boring listing of things I already knew. When I finally got around to reading it, I was surprised and delighted. It held my interest, reminded me of things I had forgotten, explained other things I had never heard of, and provided entertaining stories to illustrate each point. Best of all, the bulk of his examples are taken from medicine and relate directly to the topics we discuss on SBM.
Carroll is well-qualified to write about logical fallacies: he is a retired professor of philosophy who has long promoted skepticism and taught classes in critical thinking, and he writes in an entertaining, accessible style. He started The Skeptic’s Dictionary website in 1994 with 50 articles and it has now grown to several hundred articles. It attracts more than a million visitors a month, and some of its entries have been translated into more than a dozen languages. It has become a go-to reference for anyone seeking the facts on questionable claims about everything from crop circles to homeopathy. Its articles are thorough and well documented with lots of references and links. (more…)
We have an active comments section on our blog, but for some reason some people prefer not to comment there, but to send personal e-mails to authors when they disagree. Some of them make me laugh. Some of them make me despair. We can carry on our struggle better if we know what we are fighting; and in that spirit, I want to describe a recent e-mail exchange.
If an e-mail is filled with angry CAPITALS and abusive language, I know there is no point in responding. But I still get suckered in by the ones that start out sounding as if a productive dialog might be possible; unfortunately, discussions almost always degenerate. In this case, it started with a polite request for my opinion about a specific study. (more…)
Note: The James Randi Educational Foundation (JREF) is publishing a new series of e-books. The first two offerings are an excellent new book on critical thinking by Bob Carroll, Unnatural Acts, and the first in a planned series of republications of classic skeptical works, Homeopathy and Its Kindred Delusions, by Oliver Wendell Holmes. I was asked to write the introduction for the latter, and the JREF has kindly given their permission for me to reproduce it here.
The German philosopher Hegel said, “We learn from history that we don’t learn from history.” “Homeopathy and Its Kindred Delusions” is a remarkable little book based on two lectures Oliver Wendell Holmes gave in 1842. It is a masterful debunking of homeopathy. If his lessons had been taken to heart, homeopathy would not have survived and we could have avoided a great number of other medical delusions that continue to plague us today, both from charlatans and from well-meaning advocates who lack Holmes’ critical thinking skills.
To realize just how remarkable this book is, imagine the world of 1842. Samuel Hahnemann, the inventor of homeopathy, was still alive. Roentgen wouldn’t discover x-rays until 1895. The germ theory was not yet established. Semmelweis wouldn’t make his observations on puerperal fever until 3 years later. It wasn’t until 1854 that John Snow removed the Broad Street pump handle and stopped a cholera epidemic. Koch’s postulates for determining infectious causes of disease weren’t published until 1890. Doctors didn’t wash their hands or use sterile precautions for surgery. Bloodletting to “balance the humors“ was still a common practice. The randomized placebo-controlled trial wouldn’t appear for another century. Contemporary medicine often did more harm than good. In fact, Holmes himself famously quipped “I firmly believe that if the whole materia medica could be sunk to the bottom of the sea, it would be all the better for mankind and all the worse for the fishes.” (more…)
A Navy neurologist, Capt. Elwood Hopkins, has posted a 3-part article on “The Power of Acupuncture” on Navy Medicine Live, the official blog of Navy and Marine Corps Health Care. It can serve as a useful lesson in how not to think about medicine. It is a prime example of how an intelligent, educated doctor can be fooled and can fool himself into thinking that a placebo is an effective treatment.
To set the scene: acupuncture has been increasingly accepted in military circles. The Air Force is teaching its doctors “battlefield acupuncture” based on the faulty evidence of one Air Force doctor, Richard Niemtzow. The Army is using it to treat PTSD. The Navy offers it too.
Hopkins says that after 40 years of practicing neurology, “It was only natural to begin thinking about something else.” (Why? Boredom? And why pick acupuncture?) When he got an e-mail from his Specialty Leader announcing the opportunity for Navy doctors to learn how to do acupuncture, he submitted his application that same day. He was undoubtedly impressed that this training was being offered by the Navy, lending it the imprimatur of authority. His prior impression of acupuncture was that it was a “mysterious tool” that seemed to work; and instead of asking critical questions, he says he was looking for “a fundamental scientific understanding of acupuncture” and asking to see the supporting research and data. (more…)
In my recent review of Peter Palmieri’s book Suffer the Children I said I would later try to cover some of the many other important issues he brings up. One of the themes in the book is the process of critical thinking and the various cognitive traps doctors fall into. I will address some of them here. This is not meant to be systematic or comprehensive, but rather a miscellany of things to think about. Some of these overlap.
Everything is attributed to a pet diagnosis. Palmieri gives the example of a colleague of his who thinks everything from septic shock to behavior disorders are due to low levels of HDL, which he treats with high doses of niacin. There is a tendency to widen the criteria so that any collection of symptoms can be seen as evidence of the condition. If the hole is big enough, pegs of any shape will fit through. Some doctors attribute everything to food allergies, depression, environmental sensitivities, hormone imbalances, and other favorite diagnoses. CAM is notorious for claiming to have found the one true cause of all disease (subluxations, an imbalance of qi, etc.).