Science-Based Medicine

Publishing one excellent book is an accomplishment; publishing two in one year is a truly outstanding achievement. In 2008 Edzard Ernst and Simon Singh published a landmark book Trick or Treatment: The Undeniable Facts About Alternative Medicine. I reviewed it on this blog last summer.  It is particularly important since Ernst is a former advocate for CAM (complementary and alternative medicine) who was able to objectively look at the scientific evidence and realize that it doesn’t support most CAM methods.

Before the year was out, Ernst had published another book, Healing, Hype or Harm? A Critical Analysis of Complementary or Alternative Medicine. It is a compilation of essays on various general and specific topics in CAM. Ernst is the editor; he and 15 other authors have contributed, mostly from the UK but also including Asbjorn Hrobjartsson from the Nordic Cochrane Centre in Denmark (the author of a landmark paper on placebos), Canadian health activist Terry Polevoy, and our own inimitable James (The Amaz!ng) Randi.

In the preface, Ernst says,

Our book tries to look behind the various smoke screens that tend to obstruct our vision and often prevent us from understanding the truth. The authors of this volume have very different backgrounds and views but they are all well-informed critics who do not dismiss CAM lightly. If they disapprove of certain aspects, they do so for well-argued reasons. Continue Reading »

Four weeks ago I wrote a blog post about Sanjay Gupta’s nomination by the Obama administration as our potential new Surgeon General. Many of you voiced concerns about Sanjay’s nomination, specifically because of his poor handling of the Raelians’ Clonaid fiasco, his inability to counter Michael Moore’s health statistics as presented in Sicko and his relationship to the pharmaceutical industry.

As I wondered about what Sanjay Gupta might be like as Surgeon General – and specifically how he might assist in “restoring science to its rightful place” – I decided to educate myself about his thought processes by purchasing his recent book “Chasing Life.” The question I sought to answer was, “is Sanjay Gupta a crank?”

The short answer is: I’m not sure.  Although I wouldn’t go so far as to say that he is a crank, I think he’s more likely to be a shruggie. For those of you who haven’t read my post on shruggies, here’s the definition:

Shruggie (noun): a person who doesn’t care about the science versus pseudoscience debate. When presented with descriptions of exaggerated or fraudulent health claims or practices, their response is to shrug. Shruggies are fairly inert, they will not argue the merits (or lack thereof) of complementary and alternative medicine (CAM) or pseudoscience in general. They simply aren’t all that interested in the discussion, and are somewhat puzzled by those who are.

The longer answer involves an exploration of Gupta’s disturbing insistence on flirting with cranks, if it gets him publicity. The back cover of Chasing Life caries an endorsement from Deepak Chopra – and the inside page a favorable review from Andrew Weil. Normally, I would assume that the author of any book endorsed by those two would contain an intolerable blend of science and pseudoscience and refuse to read it. But for the sake of the readers of Science Based Medicine, I stifled my gag reflex and purchased the book. I hope that my sacrifice will benefit you all.
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“You have an irrational belief in rational thought.” ~Dr David Scholes, directed towards me.

“Humankind cannot bear very much reality.” ~T.S. Eliot

I just finished the book Mathematical Cranks by Underwood Dudley, part of a trifecta of skeptical mathematics books.

Doctor Dudley is a professor of mathematics at Depau University and a connoisseur of cranks with a mathematical bent.

What is a mathematical crank?

Mathematics is a peculiar field. Whether or not some aspects of mathematics exist independent of humans is an ongoing debate, but within its axioms and proofs is a consistent body of well defined, internally consistent knowledge.

Within that knowledge, ideas can, under the rules of mathematics and logic, can be proved or disproved, to be absolutely true or false or to be impossible.

No prior plausibility that pester the world of scientific medicine and the evaluation of woo. No borderline p values that hint at effects. No biologic variability. No placebo effect. No investigator or patient bias. No placebo effect. No N rays. No unproven water memory or meridians or subluxations.

Just clean, beautiful, mathematics. True or false. Possible or impossible. I simplify a bit, but mathematics, especially at the lower levels, is an internally consistent field of study. What happens in the math of 11 dimension string theory is beyond my puny intellect.

In mathematics there are things that are impossible. Absolutely impossible. No ifs, ands, or buts. Impossible. Can’t be done no how no way. In the world of mathematics, things are not only impossible, they are proven truly impossible within the boundaries of the mathematical discipline.

An example of mathematical impossibility is the quadrature of the circle, also called squaring the circle.

It is impossible, using only a straight edge ruler and a compass, to construct a square with the same area as a given circle. It was proved to be impossible in 1882 by Lindeman. Not improbable or unlikely or very, very, very difficult. With in mathematical reality, it is impossible.

Just because it is impossible does not prevent people from attempting to square the circle. They send these ‘proofs’ to mathematicians for comment.
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Much nonsense has been written in the guise of longevity medicine. In Fantastic Voyage, Ray Kurzweil explains why he takes 250 pills every day and spends one day a week at a clinic getting IV vitamins, chelation, and acupuncture. He is convinced this regimen will keep him alive long enough for science to figure out how to keep him alive forever. In Healthy Aging, Andrew Weil chips in with his own mixture of science and magic. I pointed out the flaws in their reasoning in a review for Skeptic magazine – available online. There are many other popular books that promise to tell you how to live longer. Most of them amount to little more than speculation based on extrapolations from animal studies, in vitro studies, and odd non-clinical facts.

There simply is no evidence that any intervention will extend the human life span. The most promising idea from animal studies, severe calorie restriction, is not practical or palatable and would make adequate nutrition difficult. We don’t know how to prolong human life to, say, 130 years; but we do know how to prevent a number of diseases from causing premature demise at 60 or 70. That’s what real “longevity medicine” means.

To counteract all the belief-based and speculation-based “longevity medicine,” we needed a science-based longevity book. And now we have it. Carl Bartecchi, MD and Robert W. Schrier, MD have written a book entitled Living Healthier and Longer – What Works, What Doesn’t. The price is right - it is available online for free download. Continue Reading »

The following book review was written not by your poster (although I’ve added the hyperlinks), but by his friend Cees Renckens, who is a gynecologist in the Netherlands and the chairman of the Dutch Society against Quackery. A short bio of Dr. Renckens, including references to several articles in English, follows the review. Most impressive to me is that he is, as far as I know, the first and only person in the world to have earned a PhD in a field that describes much of the content here at Science-Based Medicine: the rational evaluation of anomalous and implausible medical practices.

For several years, Dr. Renckens and the Dutch Society have been embroiled in a disturbing legal case involving freedom of speech. This was previously mentioned on SBM by astute reader Dr. Peter Moran. According to Dr. Renckens, the Dutch Supreme Court will issue its final judgment of the case at the end of February.

–KA

…

Complementary and Alternative Medicine: Ethics, the Patient, and the Physician. Edited by Lois Snyder, 241 pp, $69.50, Totowa NJ, Humana Press (2007). ISBN 58829-584-2. 

Reviewed by Cees N. M. Renckens, MD, PhD

During the second half of the 20th century, the Moerman anti-cancer diet was very popular in the Netherlands. Moerman was a family physician with no training in oncology or nutrition. He kept carrier pigeons and believed that his birds never got cancer. Therefore he developed a diet based on food for carrier pigeons. He had no contact with oncologists, nutritionists or other physicians. The Inspector for Public Health for his area was of the opinion that Moerman had “serious medical-ethic defects.”

Add to this example the fact that “alternative” physicians appear to be successful in presenting their approach as highly ethical, with its respect for old wisdom, for the ideas and peculiarities of their patients, and for treatments borrowed from Ayurvedic, Chinese, Tibetan and other third world medical systems, all of which can be classified as backwards, and you can understand why my interest was immediately aroused when I learned that a book had been issued with the title Complementary and Alternative Medicine. Ethics, the Patient and the Physician.

Finally, I thought, a look through ethical glasses at the deceit, at the admissibility of shoddy scientific research of “alternative” treatments, and perhaps a discussion of the necessary rigor of academic medicine and about how to deal with those who reject such rigor. When, in a short review in the Mayo Clinic Proceedings, the book was judged to be “excellent,” I dispelled my dislike of the rather high price and ordered it. 

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“You cannot reason people out of positions they didn’t reason themselves into.”

– Ben Goldacre, MD

Dr. Ben Goldacre is the author of the popular Guardian column, Bad Science. He has recently published a book by the same name. Bad Science received a very favorable review from the British Medical Journal and although I was tempted to write my own review for Science Based Medicine, I decided to cherry pick some concepts from the book instead. I hope you’ll enjoy the cherries.

Honesty & Placebos

As you can imagine, any good book about bad science must devote at least one chapter to the concept of placebos. We are all quite familiar with placebos, and how squarely the vast majority (and some would argue all) of complementary and alternative medicines fit into that category.  Ben surprised me with a couple of points that I hadn’t considered previously. Firstly, that alerting patients to the fact that you’re planning to prescribe them a placebo does not necessarily negate its effects, and secondly that no matter how skeptical or intelligent you are - all humans are subject to placebo effects.

Ben references a 1965 study from Johns Hopkins [Park et al., Archives of General Psychiatry] in which patients were explicitly told that they were going to receive a sugar pill (with no medicine in it at all) as treatment for their neuroses. The researchers reported substantial improvements in many of the study subjects’ symptoms.

This is the script that the physicians were to use to explain the placebos to the study subjects:

Mr. Doe… we have a week between now and your next appointment, and we would like to do something to give you some relief from your symptoms. Many different kinds of tranquilizers and similar pills have been used for conditions such as yours, and many of them have helped. Many people with your kind of condition have also been helped by what are sometimes called ’sugar pills,’ and we feel that a so-called sugar pill may help you too. Do you know what a sugar pill is? A sugar pill is a pill with no medicine in it at all. I think this pill will help you as it has helped so many others. Are you willing to try this pill?

Wow. I was under the impression that the efficacy of the placebo was in the person’s belief that it was a legitimate medicine/therapy. Perhaps it only matters that the prescribing physician believes it might help? Perhaps snake oil salesmen are wasting their time on linguistic and pseudoscientific mental gymnastics?

Of course, the “gymnastics” do help. Other research has shown that the more complex the associated placebo ritual, the more potent its effects (such as piercing the skin with fine needles in many different locations). Nonetheless, I was surprised that an honest and accurate description of a placebo does not necessarily negate its effects.
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Diet advice changes so fast it’s almost a full-time job to keep up with it. Avoid cholesterol; no, avoid saturated fats; no, avoid trans-fats. Avocados are bad; no, avocados are good. Wheat germ is passé; now omega 3s are de rigueur. The supermarket overwhelms us with an embarras de richesses, a confusing superabundance of choices from “organic” to low-sodium. How can we decide what to have for dinner?

Michael Pollan, the author of An Omnivore’s Dilemma, has written a new book: In Defense of Food: An Eater’s Manifesto. He argues for a simplification of diet advice. He hones it down to seven words: Eat food. Not too much. Mostly plants. Continue Reading »

In the brief time that Science-Based Medicine has existed, I’ve become known as the vaccine blogger of the group. True, Steve Novella sometimes posts about antivaccine pseudoscience and fear-mongering (unlike me, he’s even been directly attacked by David Kirby) and both Mark Crislip and Harriet Hall have each done one post about it, but, at least this far, hands down I’ve done more posts about the misinformation, pseudoscience, and outright quackery spread by antivaccine activists such as J. B. Handley’s Generation Rescue and his recently recruited empty-headed celebrity spokesperson Jenny McCarthy, not to mention a number of others who promote the resurgence of infectious disease by sowing doubts about the safety of the most effective weapon the mind of humans have ever devised against it. Truly, few uses of “alternative” medicine bother me as much as the antivaccine orientation of so much of the movement supporting it, a movement that has also led to all manner of “biomedical” treatments (quackery).

What you might not know is how I developed my interest in this particular area of dangerous pseudoscience. After all, I’m a cancer surgeon and an NIH-funded cancer investigator, not a pediatrician, immunologist, or neurologist. As hard as it is for me to believe, given that it seems today that I’ve always been refuting this nonsense, I only first discovered the antivaccine movement about three and a half years ago. True, I had been a regular on certain Usenet newsgroups for at least four or five years before that and had encountered antivaccinationists there before, but my contact with them online had been sporadic, and they seemed “out there” even in comparison to the usual run-of-the-mill alt-med maven. But then in the spring of 2005 I started to notice in a big way the cadre of pseudoscientists, parents of autistic children, and others who pushed the myth that thimerosal-containing vaccines or vaccines in general cause autism. Oddly enough, it started out with the Huffington Post, of all places. In May 2005, Arianna Huffington started a large group blog, chock full of famous pundits and celebrities writing blog posts. Within three weeks of its formation, I had noticed a very disturbing aspect of the Huffington Post, and that was that it appeared to be providing a major soapbox for antivaccinationists, including a post by Janet Grilo of Cure Autism Now, two posts by that propagandist of antivaccinationists David Kirby (with whom our fearless leader Steve Novella has managed to get into a bit of a tussle), and posts by that Santa Monica pediatrician to the children of the stars, Dr. Jay Gordon, a man who assiduously denies being “antivaccine” but parrots the most blatantly obvious talking points of the antivaccine movement and is currently best known as being the pediatrician for Jenny McCarthy’s son Evan. At the very least, Dr. Gordon is an apologist for the antivaccination movement, and he has become one of the “go-to” guys for the media looking for physicians who are “vaccine skeptics,” making numerous radio and TV appearances to promote his “skepticism.”

The next phase of my “awakening” to just how pervasive antivaccine fearmongering and pseudoscience were came when Robert F. Kennedy, Jr. wrote an incredibly dishonest and deceptive screed that got wide coverage in the summer of 2005. His article, called, charmingly enough, Deadly Immunity was a rehash of all the misinformation about thimerosal in vaccines and autism wrapped up with in a bow of conspiracy-mongering worthy of a 9/11 Truther with a penchant for quote-mining that would make a creationist blush. The article appeared simultaneously on Salon.com (which normally doesn’t publish such nonsense) and Rolling Stone, a magazine that really should stay away from science and stick to covering entertainment and politics. It was followed by a media blitz by RFK Jr. and antivaccine propagandist David Kirby, best known for his credulous treatment of the thimerosal/autism link, Evidence of Harm: Mercury in Vaccines and the Autism Epidemic: A Medical Controversy, published a few months before RFK, Jr.’s article, and his subsequent activities posting antivaccine nonsense on Huffington Post and, more recently, on the quackery-promoting antivaccine blog Age of Autism.

I’ve alluded to the fact before that I have quite a bit of blogging experience under another guise. Indeed, I’m sure many of the readers here know what that guise is. Suffice it to say that at the time I prefaced a post about RFK, Jr.’s article by saying that Salon.com had “flushed its credibility down the toilet” and referred to the article itself as the “the biggest, steamingest, drippiest turd Salon.com has ever published.” Clearly (and fortunately), I use much less–shall we say?–colorful language on this blog, but I bring this up so that the reader knows where I am coming from. Indeed, since that time in the summer of 2005, I’ve been wondering when scientists, public health officials, and physicians supporting science-based medicine would finally wake up and start to push back against this tide of antivaccine nonsense, which is starting to result in the resurgence of measles and other vaccine-preventable diseases. This year, I’ve seen some hopeful signs, including organizations like Voices for Vaccines and Every Child By Two, as well as other signs of push-back against the antivaccine movement, which, I hate to admit, has been clearly winning the P.R. war. What there hasn’t been yet is a book written from a scientific viewpoint that directly addresses the history of the recent resurgence of the antivaccine movement and refutes the pseudoscience that it promotes.

Until now, that is.
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Quacks and their apologists often cite surgery and emergency treatments of traumatic injury and a few other catastrophic or potentially catastrophic events as the only “conventional” or “allopathic” methods that they consistently recommend. Explicitly or implicitly, for most problems they tout “holistic” or “CAM” treatments. In modern medicine, however, there are plenty of non-surgical and non-emergency treatments whose outcomes are so manifest that even the most exuberant advocates of implausible medical claims (IMC) seem careful to steer clear, lest they blow their cover. Where are the promoters or consumers of homeopathic contraceptives? Why haven’t we heard of a chiropractic adjustment for high blood sugar? How many pitches for Ayurvedic treatments of gout have you seen? There are exceptions, of course, the most notable being the nearly ubiquitous anti-immunization stance among IMC promoters.

Anesthesiology and Implausible Claims

In my day job I specialize in anesthesiology, a non-surgical field whose methods are so obviously effective that little is heard from the IMC crowd. Consider: is it likely that even the slickest of the current crop of snake oil salesmen, if they had the bad sense to try, could talk many people into accepting an implausible method for rendering the body insensible to pain? No, that would require a more effective form of persuasion, such as that used in China to promote “acupuncture anesthesia” from the mid-1950s until the end of the Cultural Revolution in 1976. That’s a story I’ll tell another time.

A few other implausible claims have crept into the broader realm of anesthesiology. Stimulation of the “pericardial 6″ acupuncture point on the ventral aspect of the wrist is said to prevent post-operative nausea. There is little basis for this, the Cochrane Review notwithstanding. Verbal messages, given to a patient under general anesthesia, are said to result in “faster healing.” The major proponent of this claim is Peggy Huddleston, a self-described psychotherapist with an M.T.S. (Master of Theological Studies) degree from the Harvard Divinity School. Ms. Huddleston appears to have parlayed the “faster healing” claim into a successful entreprenurial venture, featuring a website, workshops, CDs, and a book:

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Should Medical Journals Inform Readers if a Book Reviewer can’t be Objective?

At the end of last week’s post I suggested that book reviewer Donald Abrams and the New England Journal of Medicine had withheld information useful for evaluating Abrams’ review: that he is the Secretary/Treasurer of the Society for Integrative Oncology (SIO), the organization of which Lorenzo Cohen, the first editor of the book that Abrams reviewed,* is President. I also promised to look at material from the book and from the Society’s website in order to discover “data that will allow even the most conventional oncologists to appreciate [the value of ‘integrative’ methods].”

There is little question that Abrams and Cohen know each other, or at least that Abrams couldn’t have been expected to write an entirely objective review of Cohen’s book. Abrams is the Program Chair for the Society’s upcoming 5th International Conference, sponsored by the American Cancer Society. He and Cohen will be sharing the stage for the “Intro/Welcome.” Does it matter that most NEJM readers wouldn’t have learned of this association by reading the review? Probably not, in the case of readers who are well-versed in the misleading language of “CAM.”

I believe that most readers of medical journals are not so sophisticated. Otherwise, how could it have been so easy for “CAM” literature to seep through the usual evaluative filters, not only in medical schools and government but in the editorial boardrooms of prestigious journals? For anyone from the Journal who might be following this thread, Dr. Sampson’s satirical but deadly serious account of “how we did it” is obligatory reading.

Do “Integrative Oncology” Methods have Value?

Now let’s take a look at what Dr. Cohen’s book and the SIO are up to. The book’s introduction and table of contents are available on Amazon.com. The introduction contains the usual, misleading assertions and falsehoods that are ubiquitous in “CAM” promotions. I’ve added a few hyperlinks:

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