Two Viewpoints

Most of what I read professionally is directed towards reality-based medicine. I spend my professional energies thinking about the application of reality to killing various and sundry microscopic pathogens.

The conceptual framework I use, and that used by others in medicine, does not concern itself with the application of the Supplements, Complementary and Alternative Medicines that occupy the attention of this blog. In acute care medicine SCAMs are of virtually no importance yet the approaches we need to take with patients and medicine are, with slight changes in emphasis, as applicable to SCAMs as real medicine. You need to remember, however, that the topic is not necessarily based in known reality.

Two viewpoints in JAMA caught my attention this month, both more thoughtful and reasoned than I am probably capable of. While focused on the application of reality-based medical practice, they apply to the topics of SBM as well.

The first is Evidence-based persuasion: an ethical imperative.

Evidence-based persuasion.  At some level the raison d’être of this blog and the antithesis of the SCAM world. That it is considered an ethical imperative makes its lack of use in the SCAM world all the more damning.

The article points out in the introduction that:

There are at least 3 different types of persuasion. The first is the removal of bias. The second is recommending a particular course of action and providing evidence and reasons in favor of it; and the third is the potential creation of new bias, which could cross the line into unethical manipulation.

They go on to give examples applied to the practice of medicine. How about science-based medicine?

The first kind of persuasion, the removal bias, is the primary theme of this blog. Readers and writers of this blog are aware of all the types of bias that can warp judgment. I have long said that the three most dangerous words in medicine are “in my experience” because experience is unreliable in helping decide what works.  Experience in medicine is the worst bias.

Ignoring experience is an unnatural way for humans to behave. Everything we do is a result of experience. The best restaurant in town*? The fastest way to work? Best headphones? In every aspect of life we rely on our experience and that of our social network to decide what to do. And then we get to medicine, the attempt to heal illness and relieve suffering, and we are asked to lay aside a lifetime’s approach to the world and rely on clinical trials? Not likely.

I had a patient just a few weeks ago ask me if she could take colloidal silver for her infection and I told her it does nothing. She countered that I was wrong, that she had used it many times in the past and it had always cured what ailed her. I knew I had not a chance in hell if convincing her otherwise for as Groucho said, who are you going be believe, me or your lying eyes?

Perhaps people are able to alter their biases when presented with the evidence, but I am not sure everyone is capable. When someone suggests that the reason I recommend vaccines, or any other reality-based therapy, is because I am a paid shill of big Pharma, I know that we inhabit two radically different realities that do not overlap. Such sentiments are not uncommon:

…one in seven Americans think the pharmaceutical industry is colluding to “invent” new diseases in order to profit off them…

Weird. Sure Big Pharma, like all companies, can behave with all the ethics of a psychotic shark, but the conspiratorial nature of some biases is just nuts.

In medicine when we discuss diagnostic and therapeutic interventions we sometimes have to dissuade people of erroneous ideas that could prevent them from accepting care. It is rare in my world. Most people, when acutely infected, accept the interventions I have to offer since the alternatives are rather unpleasant. The only common interaction is the occasional new AIDS patient who refuses HAART because they are convinced the medications are toxic and kill people. After explaining the history of HIV treatment I usually convince them to give it a try. As a result I have many patients who would have died in months in the bad old days who are now alive a decade later. Very satisfying.

But what if your whole practice is based on bias, on unreality, and you cannot realize it? The only bias you can alter is to convince your patients that real medicine is fantasy and that fantasy is reality. Welcome to Natural News, the bizarro world of medicine.

How about the second? “Recommending a particular course of action and providing evidence and reasons in favor of it.”  Hard for a SCAM provider.

In my practice, hospital-based acute infectious diseases, it is reasonably simple. I know most of the pertinent literature for the common infections and if I have some weird bug in an odd place I research the problem and tell the patient the whys and wherefores of the proposed treatment. I know the science, I know literature (not always the same thing) and I know the best options.

What about a homeopath or acupuncturist or reiki practitioner? Can an Integrative Medicine Department ethically offer using these therapies after comparing them to the known world?

It is an interesting psychology: based on nonsense that is a polar opposite to the understanding of reality, the only favorable evidence that can be offered is “in my experience.’ It is a curiosity that real medicine uses what can be the least convincing arguments, those from the literature, while the homeopath has to rely of the least valid but most powerful argument, experience.

My patients often want to know what kind of experience I have. Has this worked before, how many of similar cases have I managed, and what would I suggest if it were my mother? I am always slightly unnerved with the question because I know how faulty my memory is, especially after almost 30 years of medicine. That’s maybe 25,000 cases. Like I can remember? But that is all the average SCAM provider has to offer.

The last form of persuasion, that of creating new biases, is the most interesting. It is an interesting balance. Patient autonomy is paramount in US medicine. They are the captain of their ship and it is my job to give them my best opinion as to their diagnosis and treatment. On the other hand, the process of explanation will persuade them and we all know the context of how information is given can create bias.

However all SCAM is about creating new biases that are divorced from reality.

It would interesting to get an ethics consult and ask the question of a hospital’s integrative medicine department if they can live up to the recommendations of ethical persuasion:

1) Remove bias and access the patient’s autonomous wishes
2) Provide honest, impartial, evidence-based information about prospective harms and benefits
3) Provide a rational interpretation of this information including facts about the belief set and views regarding the best decision
4) Use reason rather than emotion while sometimes appealing to the patient’s emotions to counterbalance their existing emotional responses
5) Avoid creating new biases
6) Be sensitive to the patient’s changing preferences because persuasion is likely to change the patient’s outlook and perspectives.

The heart of all SCAM is in violation of the first 5. Given they are not based on known reality, they cannot follow those recommendations and it should be unethical to offered in a real medical environments.

However, SCAMs make money, and where money is concerned, rationalizations will follow.

The other viewpoint that caught my eye in JAMA was Synthesizing evidence: shifting the focus from individual studies to the body of evidence.

The first sentence is intriguing:

The research enterprise behaves as if a single study could provide the ultimate answer to a clinical question.

The rest of the essay is an argument that more emphasis should be placed on the results of meta-analyses and not rely on single studies.

I do and do not agree with the authors, but there are always caveats.

One of the issues that has always annoyed me with meta-analyses is that often as new studies are done they are incorporated into the prior analysis but the older, often more poorly done studies are not thrown out, so the bad studies tend to pull down the good ones.

The Cochran Collaboration has a nice overview of the systamatic review process but they are done under the implicit assumption that what they are reviewing are studies that evaluate reality. The Cochrane Reviews usually fail when they apply their methods to topics such as homeopathy or acupuncture, where positive results are always due to bias.

Even though they assess the quality of the studies, they do not take into consideration the prior plausibility that renders most SCAM studies suspect.

There is an arc in the literature concerning most SCAMs. Better and better quality studies demonstrate less and less efficacy until well designed studies demonstrate no effect.

The potential for that arc, as best as I can tell, is not part of the systematic review, but would give a hint as to the validity of studies where the intervention is divorced from reality. A plot of study quality vrs efficacy over time.

Part of my job is that of data synthesizer. What is the best way to treat, say, MRSA pneumonia? It can depend on many factors, some of which are not clear cut or have no data at all. Is the flu vaccine of benefit? The answer depends on what is considered a benefit and in what population; a single meta-analysis that looks at PCR-proven influenza will not include the effects on pregnancy, heart attack and stroke or the lack of spread to populations not vaccinated.

Whether or not a single study is superior or inferior to the collected wisdom of a systematic review depends on the question being asked and the plausibility of the intervention being studied.

I am not so certain that systematic reviews on fiction are a reliable way to understand the therapeutic efficacy of that fiction, but outside that caveat I agree with the authors conclusions: “It is time to focus on the entire body of evidence.”

And the body of evidence concerning most SCAM, as this blog demonstrates repeatedly, is there is no there there.


Posted in: Clinical Trials, Medical Ethics, Science and Medicine

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