Effect Measure

Wherein I respond to Orac’s counter-attack

[This is a very long post, a reply to Orac's (my respected SciBling at Respectful Insolence) equally long response to my also long original post that invited him to tell us what he thought separated his brand of medicine from the "alties" he frequently posts about. Probably most of you won't have the patience to wade through this. But a challenge is a challenge and must be met. Anyway, its Christmas Eve. Who's reading, anyway?]

I had to smile at Orac’s response to my “bit of a pot shot” across his bow with my chicken soup provocation, because that’s what it was, a deliberate provocation. And he didn’t disappoint. The pot shot produced a nuclear response. Which I sought and appreciated.

Orac doesn’t like the terms alternative and conventional medicine, but I don’t like the term “woo.” I don’t know where it comes from and find it creepy. But each to his own. So I’ll use the more accepted phrase, alternative medicine, as in “Complementary and Alternative Medicine” (CAM) and Orac can use “woo.”

First, though, I must defend myself against his charge of erecting a “straw man” argument.

. . . revere uses a strawman so dry that it threatens to spontaneously ignite. (Yes, I know I’ve used that one before, but I like it; so I used it again.) The strawman is that my position with regard to alternative medicine is that I dismiss them because “the treatment has not been shown effective via a Randomized Clinical Trial or other acceptable study design to work.” Evidence-based medicine is all about using the best available evidence to guide treatment decisions, as I have explained before in my usual long-winded manner. When randomized double-blind clinical trials are available, their results should be considered the gold standard, unless there are methodological flaws severe enough to invalidate them or cast grave doubts on their findings.

I think I was quite clear I was using the chicken soup story, which was on the wires that day, as an opportunity to inquire into something that interested me whenever I have visited his site. I have no interest in alternative medicine, but I have a real interest in epistemology and I wanted to know what his was. It seemed to me that Orac’s views are very similar to many others and he is an articulate and feisty writer. So I took advantage of the opportunity, judging correctly Orac would rise to the bait and we would all be enlightened.

In any event, I don’t know what my alleged straw man was (I can’t help observing that dryness doesn’t produce spontaneous combustion, but when you are really fond of a quip, a little scientific inconsistency shouldn’t be a barrier). I was not attacking Evidence Based Medicine (why the capitals, though?). Who could be against using evidence? I was asking what kind of evidence counted and why. In any event, Orac has done some of what I hoped: tried to explain what bothers him about the “alties.” But he defends himself against the non-existent straw scarecrow nonetheless:

Let’s take an acutely hemorrhaging patient. It doesn’t take an RCT [Randomized Clinical Trial] to tell that taking the patient to the operating room to stop the hemorrhage will save the patient’s life.

[snip]

The fact is, in surgery, much of the evidence upon which we base our clinical decisions does not come from classical double-blinded randomized studies.

His hemorrhage example is a genuine straw man. I think it was clear I wasn’t talking about things for which common sense and patently obvious mechanisms are involved or for which one cannot ethically do an RCT. I’m an epidemiologist and believe in the value of controlled observational studies, not just randomized trials, but even there I don’t think you need an epidemiological study to show that having the slats in a baby’s crib too far apart is dangerous. One accidental strangulation case report is sufficient. Maybe Orac was misled by my adding the phrase “other acceptable study design” and perhaps it is too formal sounding. It was meant to include any kind of evidence he would warrant as informative or reliable and my purpose was to find out what he thought that was. I still don’t know.

I grant that RCTs are not common for surgical procedures, for good reasons. What then, are the grounds for many of the procedures that are done? In other words, what is the next “best evidence”? I’m not saying there isn’t any. I’m just asking, as a non-surgeon, for a surgeon to tell me what justifies a lot of the procedures he and his colleagues do since they are, by his own admission, untested by his gold standard. He doesn’t say whether many are actually tested in any way, although I believe many aren’t. What are Orac’s standards beyond his gold standard or some good observational study design? Is it clinical experience? Is it an inference from some known mechanism? And when there are options, i.e., different ways to carry out a procedure or even a choice between medical or surgical management, what justifies his choice? I am asking because I think it is fair to ask these questions of someone as highly critical of others as Orac is. He gets to some of this, which we will get to, too. Let me dispose of some of things that Orac said along the way.

Orac and others who inveigh against “alties” often accuse them of magical thinking, a charge I considered perfectly fair. But here was what I said about that charge:

A variation of this is that the proposed explanation is “magical thinking.” That’s perfectly fair as a criticism. Unfortunately, proposed counter-explanations [like placebo effect] are also vulnerable. If one takes “the placebo effect” to mean an interaction between the mind and the body that produces an effect, that’s at the level of magical thinking in my book. If you provide a neurophysiological explanation that’s fine (assuming you can give one). But then the remedy is actually having a physical effect so what’s the problem? It’s like a psychoactive agent. Counter-irritation as an assumed mechanism [to explain acupuncture anesthesia] is another irritating wave of the hand that seems quite magical to me. What exactly is the mechanism of counter-irritation, say, for acupuncture anesthesia? If you give me one then aren’t you giving me an explanation for how acupuncture really does work? If you can’t, why isn’t that a “magical explanation”? Or is the complaint about some alternative therapies that they might work but have the wrong reason? In which case much of conventional medicine is probably also in big trouble.

As an aside, it turns out that Orac is skeptical of both the placebo effect and acupuncture. His attitude toward placebos I find a bit extreme. His standard seems to be that there is no real effect since it don’t really work because it can’t do the really hard tasks like curing cancer. Obviously there is a well-documented placebo effect, however. That’s why we use them as comparisons in RCTs. The real point of my point, however, was to try to ferret out the role that the proposed explanation or underlying theory plays in telling alternative therapies from conventional ones. Here is his answer:

Let me lay it on the line here: I am not so much disturbed by treatments that are efficacious for which our understanding of the mechanism is incomplete or lacking as I am about the attribution of mystical B.S. to such treatments or to making claims for such treatments when there really isn’t compelling evidence that they “work.”. As revere points out, there are a fair number of treatments in conventional medicine for which the physiological mechanism is poorly understood or unknown. However, unlike the case for alternative medicine, we actually do have compelling evidence to support the efficacy of such treatments, and it is not true that possible explanations for their efficacy fall outside the realm of scientific plausibility based on our current understanding of human biology. For the example of asbestos, there are any number of plausible biological mechanisms based on our current understanding of chemical carcinogenesis by which asbestos particles could cause lung cancer. We just don’t yet know which one(s) to attribute its carcinogenic affect to [NB: this is incorrect about asbestos, but the error on Orac's part isn't germane to the argument.] Revere mistakenly conflates such scientific uncertainty with my overall message about the implausibility or virtual impossibility of much of alternative medicine. What I’ve been talking about is alternative medicine therapies where the mechanisms by which they are said to work are highly implausible physically, biologically, chemically, based on what we know. Good examples of this include homeopathy, which, if true, would violate our present understanding of physics, chemistry, and pharmacology to the point that many well-accepted theories would have to be overthrown, and something like Reiki therapy, for which no “life force” (qi) has ever been detectable or changes in such a force noted in response to the ministrations of a Reiki master.

Note that Orac has slid over the cases where there is no demonstration of efficacy in conventional medicine, perhaps the major category. For the rest, this does seem to be just what I said it was, a confusion between whether something does work or not with whether the reason given for any efficacy makes sense to Orac in terms of his own understanding of what is allowable scientific explanation. We see the same arguments given by physicists who say that non-ionizing electromagnetic radiation cannot possibly have a cancer effect because this is physically impossible: it is non-ionizing and therefore can’t have chemical effects. Meanwhile there is a respectable body of good epidemiology to show cancer effects and epidemiology that fails to show it. This has to be sorted out. But if we were to listen to the physicists (and Orac) we wouldn’t bother any longer to do any studies.

Orac is willing to listen, however, but only if the evidence is absolutely clear:

Even for twaddle like homeopathy or Reiki, I would still be willing to consider throwing out what we know and massively revising it in the light of new knowledge if compelling objective evidence for efficacy were presented for the real efficacy of either homeopathy, Reiki therapy, or any other alternative medicine to which an amazingly implausible mechanism of action is attributed. None ever has, as of yet. As Dr. Mark Crislip of QuackCast (someone who is even more–shall we say?–insolent than Orac is, but nowhere near as respectfully so, and that’s saying something) put it in his podcasts on the evidence regarding homeopathy and acupuncture, as the quality and rigor of the clinical trial increases, the “effects” attributed to homeopathy and acupuncture tend to decrease until they are no better than placebo in the best clinical trials with the largest number of patients.

The confusion between a plausible mechanism and efficacy is evident here, too. He’d believe evidence that something works if we could present him with compelling evidence. Yet he doesn’t demand compelling evidence for efficacy for the many things surgeons and others do for which he has one or more (possibly contradictory) plausible scientific explanations, however he understands what a scientific explanation is. We also see here that placebos are assumed to have an effect, at least by Dr. Crislip. So if placebos really do work (and if they don’t then why test against them?), then all these alleged failures of acupuncture show is that they work, but no better than placebos. Let me say again, I don’t know if acupuncture works or not, nor do I much care. My interest is in what Orac thinks counts as a scientific explanation, which is the linchpin of his whole system.

At this point, Orac brings in our mutual SciBling AbelPharmboy of Terra Sigillata here at ScienceBlogs:

The basis for generating a hypothesis to test whether an alternative remedy has biological efficacy must have some scientific basis that is sound. I’ve heard herbalists tell me that “whole herbs” are superior to purified compounds because of synergy among components or because one herbal component blocks a side effect of an active component. These are both reasonable scenarios, but there is a great paucity of evidence in the literature to support such suppositions…
However, if an herbalist tells me that a whole herb works better than a pure compounds because the herb is “energized” or contains a “life force” that is extracted away by laboratory purification, I call bullshit unless there is a method to quantify these forces and demonstrate their causality with biological activity.

That’s fine, as a consistent criterion, as long as it applies to everything. But by Orac’s own admission, much of what we do in medicine cannot be quantified in that fashion. Few of us doubt that “bedside manner” is an important component in much clinical success (well, maybe we should excuse surgeons from this), but we can’t quantify it most of us wouldn’t call it bullshit.

We now come to Orac’s battlecry:

My battle cry as far as these so-called “alternative” therapies is, “Show me compelling evidence that they work if you expect me also to radically alter my view of how human biology works!” My corollary to this battle cry would also be that, if you want to get grant funding — taxpayer money — to study your woo, you should be able to show at least one of two things: biological plausibility or compelling evidence that the woo in fact does what you claim that it does, preferably (but not necessarily) both.

I think this is a very conventional view, and one to which I don’t necessarily object, but I feel compelled to make some observations about it. For example, it is a recipe for “in the box thinking” that is OK for everyday science but not very promising for innovative science. Orac makes mention of spending taxpayer money to study alternative therapies (a reference, perhaps, to his on the record objection to the NIH grant program that studies the efficacy of Complementary and Alternative Medicine), but it appears to be a self-fulfilling prophecy. You shouldn’t study if it works if there hasn’t been a study to show it works or you have reason to think it might. The history of science is littered with examples of things that “shouldn’t work” or “shouldn’t happen” (and are often denied to be happening at all) but that do, and whose eventual explication results in a major step forward. I not only do grant reviews for NIH (as does Orac) but I chair grant review panels, so I am well aware of the standards and practices that go on there. The problem of a bias toward “safe” science is one most of us who have been around a long time recognize and are concerned about.

Finally, Orac takes on the Demarcation Problem (separating science from pseudoscience) and references Janet’s excellent explication of Popperism at Adventures in Ethics and Science. I should let Janet speak for herself, but it wasn’t my impression she was advocating Popperism’s falsifiability criterion as a workable standard. Few philosophers would do that because it is so obvious it doesn’t work in practice. For those of you unfamiliar with the ideas, I refer you to Janet’s fine post on the subject, but here is my short, crude version for purposes of making a point. Popper says that a theory that posits that all ravens are black is never established by repeated examples of black ravens (confirmation) but it can be overturned by one example of a non-black raven. Thus there is an asymmetry which argues for a strategy of falsifying your propositions as the true hallmark of a scientist. Like many scientists, Orac buys this. Of course it doesn’t work that way. The response of the scientist to his colleague’s demonstration of a non-black raven is more likely than not going to be something like, “A raven? You call that a raven?” There are many responses to this, such as Quinean pragmatism, but that’s for another post.

Here I will only observe that Orac seems to accept that telling science from pseudoscience is a simple matter of seeing whether the explanation accords with his idea of what is conventional science. Would that it were so easy. I wanted to know what his idea of what science was, but all I got is that science is whatever he says it is or at least, whatever the books say it is. The idea that science is whatever scientists do is fine, maybe even the right way to look at it, but then the question comes down to who gets to say who is a scientist and why.

Part of Orac’s attitude may be related to his notion of physician exceptionalism.

In fact, here’s where real humility comes in and why this demarcation problem is somewhat different in medicine than it is in the rest of science. The difference is, boiled down to its essence, patients, and if anything distinguishes “conventional” medicine from “alternative” medicine, even when evidence may be scant for some “conventional” interventions, it is the humility in presenting his treatments to the patient. Yes, humility. However much people joke about the “God complex” of doctors, this attitude is nothing compared to the attitude among true woos. Despite their seeming otherwise, quacks and pseudoscientists are anything but humble and honest about their limitations. In non-medical areas, pseudoscientists often claim that scientists are wrong, that they know nothing, and that their woo will replace current science, all on minimal evidence. While such hubris usually doesn’t do that much harm, other than to the pseudoscientist’s reputation, in medicine it is disastrous to patients. Quacks claim to have the cure for cancer or even the cure for all diseases. They often disparage conventional medicine, claiming that their woo is better and can cure the patient without the risk of all those potentially nasty complications or side effects that we conventional doctors have to acknowledge and warn the patient about. Patients, afraid, desperate, and all too often distrustful of “conventional” medicine because of its known shortcomings, too often fall for the blandishment of quacks and suffer, often from a delay in receiving effective therapy until it is too late, accompanied by a draining of their bank accounts. Dr. RW described this difference well while asking When Woo Overlaps Mainstream Medicine, Can Patients Sort it Out?:

It seems to me that this boils down to, “Maybe we aren’t great, but they are worse.” I have no doubt Orac is a truly excellent physician and also little doubt the humility which he describes is characteristic of his own practice. But to say it is the norm is really asking me to believe a lot. The average clinical encounter continues to shrink and there is less and less time to do the things most physicians never did well anyway. My son recently had (successful and uncomplicated) arthroscopic surgery for an athletic injury. He never saw the surgeon and never had the procedure or the condition explained to him. The surgeon is a famous orthopedist practicing in one of the best and most famous academic hospitals in the US. He did an excellent job (I hope) and my son’s shoulder should be stronger than before. But this surgeon is more the norm than the exception. Orac’s rendition of the humble doctor as representative is even more incredible than Reiki. I would guess (maybe Orac has some data on this) that more people visit alternative practitioners after exhausting (and being exhausted by) conventional treatments that failed than instead of them.

I have no doubt there are many crooks purveying quack remedies for profit or because for some reason they believe they work. Some of them do a lot of harm, and it isn’t difficult to find examples. But it isn’t difficult to find examples of conventional practitioners who can be similarly described. In fact, we could do a Global Search and Replace in Orac’s paragraph above and interchange conventional and alternative therapies and come up with an equally common and equally valid description of a great deal of conventional medical practice.

Orac continues in this vein, claiming ethical superiority for conventional practitioners by virtue of their science:

. . . one other huge area of “demarcation” between woo and non-woo in medicine. And Dr. RW is also very correct in pointing out another important aspect of differentiating woo from non-woo in medicine: ethics. Dr. Maurice Bernstein also points out that it is up to the physician to try explain to the patient what is and is not evidence-based about his recommendations because it is his fiduciary and ethical duty to the patient:

What has all of this to do with medical ethics? It has to do with the physician’s duty to be trustworthy to the patient and to aim to do good and not produce harm to the patient. Informing the patient, unless some patient rejects being informed, is also duty of the physician and is part of the consent to treatment process. It should be a standard of medical practice that the patient understand what portions of the physician’s decisions regarding diagnosis, prognosis or treatment is based on reliable evidence and which is based on hearsay or simply statistically not verified experience. But do most physicians have the time or skill to explain to the patient on what basis their decisions were made? Further, do most physicians even know which of the “facts” they are using have not been rigorously proven? Unfortunately, even with the best of physician attention to educate themselves on the evidence and to explain this to the patients, there is much in medical care that will remain “old tales” either because there is not sufficient interest to provide the time and expense to do scientific studies or realistically because some studies just can’t be accomplished because of technical or ethical issues.
The real Demarcation Problem between quackery and evidence-based medicine, I would argue, is the willingness to be always striving to test our therapies against new therapies in the search for better ways to care for our patients versus stagnation, dogma, and unquestioning faith in a treatment on the basis of little or no evidence. Scientific medicine embraces the former; alternative medicine embraces the latter.

Dr. RW’s ethical prescriptions, referred to by Orac, are mostly honored in the breech, leaving conventional practice no more ethical than alternative practice and frequently far less caring. This also is quite an arrogant position. “We are superior because we care enough about our patients to test our therapies.” But of course most aren’t tested, for one reason or another, and most doctors don’t even know whether they have been tested or not. We learned them in school and we keep doing them. Orac and I are academic physicians and not at all typical. Furthermore, everything hangs on Orac’s claim of a “willingness to test,” yet he doesn’t make clear what he means. This shows that rather than being exceptional, the Demaracation Problem is the same for physicians as for other scientists, and his version of it is “testable.” This is a highly problematic criterion for philosophers, if not for doctors.

Finally, we have this:

As far as I’m concerned, and as I have said over and over again since the very beginning and even before [?!], there is no such thing as alternative medicine. In my book, the approach to evaluating the therapeutic value claimed for a treatment should be the same, regardless of whether the treatment is considered “alternative” or not. The gold standard would be an RCT, but if it’s not possible to do an RCT then the best existing lesser evidence must be accepted and evaluated as the basis for using the treatment until better evidence is developed, lest we suffer “evidence-based paralysis” or “RCTomyopia.” The patient’s disease won’t wait, in other words, and we as physicians have to do the best we can and use the best scientific evidence available to decide upon the best course of treatment for any given patient. Sometimes that means, in cases where evidence is very sketchy or conflicting, to use primarily anecdotal or personal experience as a guide, even though that’s far from ideal.

Yes, it’s a dilemma, because frequently there isn’t any evidence of efficacy, only an argument of plausibility. Here is Orac’s solution:

Emily correctly points out that conventional medical treatments aren’t always evidence-based. She asks “Is that not, in effect, a form of woo, too?” The breach between evidence and practice to which she refers, let’s call it the quality chasm, while every bit as serious as woo, is not in fact woo in most cases. The quality chasm is not a result of outlandish or implausible claims, (e.g. that water has memory) and that’s what distinguishes it from woo. The quality chasm results from an extremely complex interplay of cognitive and system barriers to the consistent application of best evidence in practice. Mainstream medicine recognizes the need for widespread system change and promotion of evidence based medicine. Although there’s no simple fix to the quality chasm, many in mainstream medicine are trying, which is in ironic contrast to the fact that mainstream medicine also increasingly promotes woo. For the mainstream, especially academic medicine, to promote woo is to engage in unethical scientific pretense and active deception of patients.

In other words, “woo” and untested conventional practice are the same except that conventional practice doesn’t make “outlandish” claims about how it works. “We” are better because some of us are trying to figure out what works. At the same time, Orac doesn’t like NIH’s grant program to actually test alternative therapies because he already knows they don’t work, it’s a waste of money and it gives aid and comfort to the enemy.

What it comes down to for me is not so much that I disagree with Orac about whether much of what alternative therapies is correct as much as I don’t like the certitude with which he says it, often, it seems to me, with uncertain grounds. You can be right for the wrong reasons and wrong for the right reasons, one of the issues raised by the claims and counter claims of conventional medicine and its rivals (and I put it that way deliberately, for historical reasons).

It doesn’t seem to me Orac has escaped this, no matter his degree of certitude.

Comments

  1. #1 Mike
    December 24, 2006

    re: names – How about So-called Complementary and Alternative Medicine?

  2. #2 Phila
    December 24, 2006

    Not that my opinion matters, particularly, but I’d side with Revere on this one (and not just ’cause the term “woo” is so goddamn irritating).

    There seems to be a typical confusion here between science as a quasi-Platonic ideal, and science as a field. While mainstream medicine may currently recognize “the need for…promotion of evidence based medicine,” the production of evidence is not necessarily politically or economically disinterested. And of course, the best evidence available at a given time doesn’t reliably provide guidelines for ethical medicine (the Tuskegee syphilis experiment was “evidence-based,” after all).

    While there are serious concerns about quack medicine, those concerns apply as much to, say, the current system of pharmaceutical testing and promotion as they do to homeopathic nonsense. It seems to me that both sides are a bit too eager to promise simplistic, one-size-fits-all quick fixes, whether that means blithely prescribing the latest miracle pill from Merck, or blithely recommending ear candling.

    I don’t think medicine can ever really be autonomous from politics and economics, and I also question how much it can be improved, practically speaking, while the current political and economic dogmas hold sway. The movement for evidence-based medicine is admirably high-minded, and in theory it makes a fair amount of sense. But in practice…well, some evidence can legitimately be seen as a product – in the Economics 101 sense – of research, and it’d be a mistake to glorify it as some pure emanation of rationalism and objectivity. For the average citizen, seeking medical treatment of either type often involves a dramatic – and potentially dangerous – leap of faith.

    That’s what I think, anyway.

  3. #3 Phila
    December 24, 2006

    For the average citizen, seeking medical treatment of either type often involves a dramatic – and potentially dangerous – leap of faith.

    I probably should’ve said “sometimes,” rather than “often.”

  4. #4 G in INdiana
    December 25, 2006

    No Phila, you were right about often.
    Even using over the counter drugs like aspirin or
    tylenol requires a leap of faith. Having surgery
    requires you to have faith the person cutting you
    up is going to do the right job, that the people
    who care for you after wash their freaking hands
    in between patients (my dad died due to a nonsocomial
    infection so this is a HUGE leap of faith for our
    family), or that the person who diagnosed you in the
    first place has their head on straight that day (my
    kid’s paternal granddad died due to a misdiagnosed
    heart problem.. they thought it was indigestion).
    In our family’s experience, any medical care no
    matter whether it is alternative or conventional
    is ALWAYS a leap of faith because you are counting
    on another fallable human being to do the right thing.

  5. #5 Ron
    December 25, 2006

    This has been a great exchange on epistemology and I have enjoyed it very much. I think Revere has touched a couple of key points that should be emphasized. One is the reference to science inside the box vs. innovation. Science is a very sure way of validating our knowledge, but it is very slow and limited. It is like looking at the universe through a pinhole. We have a lot of control over the light coming through the pinhole and maybe think we know a lot about it. But when we make decisions in our life we have to stop looking though the pinhole and consider our situation in the world as we perceive it holistically, much of which is still beyond the understanding of our science. And so a healer must decide what to do with complex real world illness.

    Thus,( the second important point) many in our culture, perhaps most, turn to alternative therapies when ‘scientifically-based’ medicine fails to provide results. It would be well to remember Wittgenstein’s criticism of Frazer’s Golden Bow. He takes Frazer to task for defining ‘magical thinking’ as a kind of ‘failed science’ and charlatanism. W’s point is that magical thinking is not failed science because it is not trying to be science in the first place, it is not trying to explain the world scientifically. Magic attempts to make sense of our experience, including levels of psychology, myth, social relations, identity and sense of history, ethics, etc. Science simply may be irrelevant to much what magical thinking is trying to do.

    If you study traditional medical systems (as I do in with the Mayan Indians of Chiapas) then you find out that medicine in these cultures is much more than empirical cures for clinically described diseases. In fact, most of the herbal remedies and procedures used by traditional healers turn out to have ‘scientific’ validity—e.g. the herbs turn out to have ingredients with physiological effects that correspond to the empirical purposes of the healers, etc.. The process of healing as a whole, however, is much more complex than just administering herbal remedies, involving an etiology of soul loss and harmonization of the patient’s social relations. It is a ritual process of ‘reintegrating and reoriginating’ as one anthropologist put it. When you work with people who take responsibility for the health of their communities in extremely adverse conditions of poverty and racial discrimination, the term ‘woo’ seems particularly offensive, and the proposal that cosmopolitan doctors are ‘more responsible’ to their patients a cruel joke.

  6. #6 Ron
    December 25, 2006

    I meant ‘The Golden Bough’. Sorry

  7. #7 Phila
    December 25, 2006

    any medical care no
    matter whether it is alternative or conventional
    is ALWAYS a leap of faith because you are counting
    on another fallable human being to do the right thing.

    Posted by: G in INdiana | December 25, 2006 09:28 AM

    Sure. And I certainly know of examples from my own circle of acquaintances where conventional medical treatments turned out to be faulty or worse. Hell, we’ve had several instances in the last couple of years where we got prescriptions that were either strongly contraindicated for our conditions, or flat-out wrong.

    As for alternative stuff…I remember getting a panicky call from a friend whose room-mate was sick. The other room-mates had put her in a tub full of “healing herbs,” but my friend thought she might need real medical care. I’m not a doctor, but after asking a couple of questions, I became pretty sure the woman had meningitis. Either way, though, it was obvious that she needed to get to an ER immediately. I convinced my friend to get the gal out of the tub and over to the hospital right away (she had a kidney infection, as it turned out).

    The image of someone being soaked in a bath full of dried flowers while afflicted with a high fever, splitting headache, photophobia, and vomiting is downright medieval. And these, amazingly, were reasonably well-educated people…not stupid, by any means.

    I’ve experimented with a fair number of herbs, out of curiosity. I find a few to be reliably helpful (elderberry and deglycerrhizinated licorice, for instance). Most others, I might as well have been chewing a handful of grass while tossing money down a well. Helpful or not, though, people are going to continue using them (people without health insurance, especially, for whom herbs are “alternative” in much the same way that sleeping under the overpass is an alternative to getting Section 8 housing). While I don’t think it’s feasible to ban them, I do think they ought to be checked stringently for purity and dosage. I’m less concerned by the self-medication than by the fact that people don’t necessarily even know what they’re getting.

    Ron’s point about Wittgenstein and The Golden Bough is interesting. I’d point out that science – or at least its terminology and superficial appearance – has long since been incorporated into, or even replaced, magical thinking in Frazer’s sense. (I’m sure we’ve all seen quack remedies explained by recourse to quantum entanglement or Feshbach resonances, or what have you). If I recall, W was talking more about ritualistic behavior within a codified tradition (e.g., Mayan medicine in Chiapas), which I see as very different from the fragmentary, confused, blindly groping state of modern irrationality (just as St. Augustine’s Christianity is much more “effective,” as a system, than that of the nitwits in the Intelligent Design camp).

    When you work with people who take responsibility for the health of their communities in extremely adverse conditions of poverty and racial discrimination, the term ‘woo’ seems particularly offensive, and the proposal that cosmopolitan doctors are ‘more responsible’ to their patients a cruel joke.

    Well said. Couldn’t agree more.

  8. #8 DeadAhead
    December 25, 2006

    Sorry, I’m not at all certain because I don’t know all that much about homeopathy, but mightn’t this practice qualify as such?

    Study: Overcoming Allergies Possible
    By THE ASSOCIATED PRESS
    Published: December 25, 2006

    Filed at 2:05 p.m. ET

    WASHINGTON (AP) — Elizabeth White’s first encounter with peanuts — a nibble of a peanut butter cracker at age 14 months — left the toddler gasping for breath. Within minutes, her airways were swelling shut.

    A mere fifth of a peanut was enough to trigger an allergic reaction.

    So it was with trepidation that her parents enrolled Elizabeth, at 4 1/2, in a groundbreaking experiment: Could eating tiny amounts of the very foods that endanger them eventually train children’s bodies to overcome severe food allergies?

    It just may work, suggest preliminary results from a handful of youngsters allergic to peanuts or eggs — and who, after two years of treatment, seem protected enough that an accidental bite of the forbidden foods is no longer a huge threat.

    ”We’re so lucky,” says Carrie White, Elizabeth’s mother.

    Now 7, Elizabeth can safely tolerate the equivalent of seven peanuts. For the first time, the Raleigh, N.C., girl is allowed to go on playdates and to birthday parties without her parents first teaching the chaperones to use an EpiPen, a shot of epinephrine that can reverse a life-threatening reaction.

    ”Our whole worry level is really gone.”

    Don’t try this experiment on your own, warns lead researcher Dr. A. Wesley Burks of Duke University Medical Center. Children in the study are closely monitored for the real risk of life-threatening reactions.

    But if the work pans out — and larger studies are beginning — it would be a major advance in the quest to at least reduce severe food allergies that trigger 30,000 emergency-room visits and kill 150 people a year.

    ”I really think in five years there’s going to be a treatment available for kids with food allergy,” says Burks.

    Millions of Americans suffer some degree of food allergy, including 1.5 million with peanut allergy, considered the most dangerous type. Even a whiff of the legume is enough to trigger a reaction in some patients.

    Moreover, food allergies appear to be on the rise. Peanut allergy in particular is thought to have doubled among young children over the past decade, prompting schools to set up peanut-free cafeteria zones or ban peanut-containing products.

    There’s no way to avoid a reaction other than avoiding the food, something the new research aims to change.

    Allergies to pollen and other environmental triggers often are treated with shots called immunotherapy. A series of injections containing small amounts of the allergen builds up patients’ tolerance, reducing or even eliminating symptoms in many people.

    Shots proved too dangerous for food allergy. So Burks and colleagues at Duke and the University of Arkansas developed an oral immunotherapy.

    Here’s how it worked: First, youngsters spent a day at the Duke hospital swallowing miniscule but increasing doses of either an egg powder egg or a defatted peanut flour, depending on their allergy. They started at 1/3,000th of a peanut or about 1/1,000th of an egg, increasing the amount until the child broke out in hives or had some other reaction.

    Then the children were sent home with a daily dose just under that reactive amount. Every two weeks, the kids returned for a small dose increase until they reached the equivalent of a tenth of an egg or one peanut — a maintenance dose that they swallowed daily.

    After two years, four of the seven youngsters in the egg pilot study could eat two scrambled eggs with no problem, and two more ate about as much before symptoms began, researchers report in the January edition of the Journal of Allergy and Clinical Immunology.

    In the peanut pilot study, yet to be published, six of the children challenged so far could tolerate 15 peanuts, Burks says; Elizabeth’s limit was seven.

    ”We thought it would make some difference. We’re surprised about the amount of difference it made,” says Burks. ”From one peanut to 15 peanuts is basically a huge difference.”

    But will it last? These youngsters still take their daily maintenance dose, which Elizabeth’s mother nicknamed ”peanut medicine” so as not to confuse a child taught to avoid peanut products. No one knows if the protection will last if they stop that daily dose, notes Dr. Marshall Plaut of the National Institutes of Health, which has a Food Allergy Research Consortium that’s closely tracking Burks’ work.

    The next step: Burks’ team is beginning larger studies that randomly assign youngsters to take either dummy powders or the egg- or peanut-containing ones, seeking better evidence for the treatment.

    He’s also giving patients like Elizabeth larger doses, to try to increase their resistence to the allergens. Blood tests signal promise: People who tolerate higher doses in turn have lower blood levels of a compound called immunoglobulin-E that’s key to immune cells’ overreaction to allergens.

    ”Inducing tolerance is an attractive approach,” says NIH’s Plaut. But, ”you don’t go into this kind of a study lightly” because of the risks.

    ”It’s not something we’re ready for everybody to do yet,” stressed Burks.

    ——

    EDITOR’S NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.

  9. #9 revere
    December 25, 2006

    DeadAhead: I don’t think this is homeopathy. This sounds like fairly standard desensitization practice. In homeopathy, not only are subjects given agents thought to produce the same symptoms or signs as the treated disease, but they are given them in vanishingly small amounts (by serial dilutions that by calculation are unlikely to contain many or even any molecules of the original stock) and finding the right “remedy” is one of the arcane arts involved. Thus a treatment failure is put down to the wrong remedy, not the wrong theory. At least that’s what I understand of it, but I hasten to add that my study of it has been mainly historical. Contemporary homeopathy seems to have many elements of various kinds of naturist, botanical and herbal practices, too, and I know little about this aspect of things. However with respect to “like cures like” I don’t think the peanut example is true homeopathy. Maybe others know better than I.

  10. #10 Phila
    December 25, 2006

    Sorry, I’m not at all certain because I don’t know all that much about homeopathy, but mightn’t this practice qualify as such?

    It’d be isopathy, if anything. But the larger issue is that homeopathic remedies contain nothing but water (or sugar, in the case of pills). Regardless of whether one believes in homeopathy or not, its assumption that some spiritual imprint of a molecule remains in water no matter how many times it’s been diluted puts it far, far outside the methodology of inducing tolerance to allergens. You might as well say that a particle accelerator is a form of philosopher’s stone.

  11. #11 DeadAhead
    December 26, 2006

    Thanks, revere (and Phila) –
    I have been gathering that many so-called homeopathic remedies these days stray far from whatever that practice was. I have some little under-the-tongue sinus pills that seem quite effective against low-grade irritation, with recognizable herbal ingredients. So the term homeopathy has become a sort of off-mark naturist brand….
    I can say that these pills have saved me most of the time from taking the much stronger ones that had been my custom.
    I appreciate your sensibility in challenging your friend’s rather fetishistic adherence to a “scientific” approach that often lacks integrity, vs a “natural” one that on occasion delivers results. They overlap when big pharma patents an herbal solution, frequently by adding crud to it.
    We should all be skeptical of ALL proposed solutions to physical issues. It goes back to the truism that everything of value bears some cost; there’s no such thing as a free or easy cure.
    Unless we count sunlight and exercise!
    Stay well,
    DA

  12. #12 Darin
    December 26, 2006

    My friend, an ER doc, and I argue of whether there is a capital T truth out there or not. I’m the relativist. One of things that I realized during the course of our conversations is that is that being a Truth seeker is very important for being an ER doc, that there is one best way to treat this patient. I’m sure the same goes for surgery. Deep down I wonder if the point-counterpoint is not about the validation of proper science, but really the chicken and the egg. Did Orac the surgeon choose surgery because he believes there is a best practice a.k.a. EBM that should be used or did he choose surgery and then move to this epistemological point-of-view. The same could be said for Revere or anyone for that matter. We do not have epistemological beliefs independent of the rest of our experiences.

    We experience, we make judgments, we change our point of view, and we change our epestimologal beliefs. Sometimes we change any or all of the above ex post facto to resolve our cognitive dissonace. Personally, I am a cMPH in epi, and I’m a relativist. If I weren’t a relativist, I would have a hard time even considering that a well designed observational study is even worth doing. By pragmatism, Orac suggests that RCT are not feasible in surgery and that the next best prove-to-me-that-this-is-an-acceptable study design should be implemented.

    As a physician, it is easy to have an ethical obligation to expect the best information. But we strip ethics out of the way for the sake of conversation, what then is the minimum threshold for proof of acceptable practice? I assert that the best information is the one you have at the time you make the decision. How do we know if this the best? Face it, we don’t, we make a fallible human decision with what we have. We do our due diligence so that we may sleep at night. Some are more diligent or expect more, but in the end it’s all relative.

    As for woo, CAM, and all that crap. You might as insert religion and atheists as the term. Only the old school would have you/us/me think that the terms of this conversation should be about whether God exists. As if modern medicine is the right or best way to do things for perpetuity. There will be better techniques, information, drugs available in the future just as many thought the Greek myths were passe’ so will we think that our current medicine is arcane. No capital T Truth here, please move along.

  13. #13 revere
    December 26, 2006

    Darin: well, not quite so easy, of course. Most scientists (let alone ER docs) are spontaneous realilsts. We believe there is a real world out there, it exists independently of us and that science is a reliable way to “know” that world, although no infallible or final. But there is a solid reality out there and it doesn’t depend on what we think it is. What you call the “relativist” position (related I presume to social constructivist views) is now a bit passe, but it had the salutary effect that most scientists will now acknowledge that social and political views affect how we do science and what is in fashion or not at any particular time. Similarly, most of the hard edged criteria for demarcation are gone. Philosphers now acknowedge the we haven’t solved the Demarcation Problem or at least reached a consensus on it. In this regard, scientists are extremely backward, thinking it was solved long ago as a testability criterion, perhaps embellished with a falsibiliability slant. Few philosophers adhere to Popperism these days. It didn’t work in practice, much less theory.

    Two philosophers who try to reconcile the science wars are Ian Hacking and Susan Haack, both of whose works I recommend.

  14. #14 Ken Camargo
    December 26, 2006

    Hello,
    Thanks for articulating this position so well. There are a few fine points that in my opinion merit more discussion, though.
    Although I can understand and agree with the observations you make with regard to what Orac wrote, there is one aspect I’d still agree with him to some degree, that of “humility” (although I’m wary of couching an epistemological argument in moral terms), maybe not of practicioners but of advocates. I think he does have a point in that at least some of the more outspoken advocates of CAM do tend to make outrageous claims of efficacy; as someone who wrote a few things about the epistemological shortcomings of biomedicine, I find it a bit annoying to find those people quote my criticism and then move on to make preposterous claims about their own set of beliefs/knowledge, which they seem to believe to be immune to the same sort of criticism, in a flagrant display of lack of balance in their views. Another issue with this regard is the tendency to concoct pseudo-explanations throwing in loose terms stolen from other disciplines (usually quantum mechanics), creating epistemological chimeras that are wrong on so many levels that I don’t know even where to start commenting (I’d propose a law: at least nine of ten times when a non-physicist invokes quantum mechanics to “explain” some unorthodox theory, (s)he will be inevitably wrong).
    On the other hand, I think the argument about the placebo effect (or what I’d rather call, from an anthropological perspective, symbolic efficacy) is just perfect. We could imagine a research programme that would seek to enhance that efficacy, but the standard research practice (RCTs) is geared towards ruling out its effects. Maybe the complexity of mediations involved will preclude a full-fledged determinist explanation of how this set of ideas ends up producing this sort of physiological effects, but that sort of detailed pathway is not a requirement for using drugs that went through RCTs either.
    Finally, I think you are being too hard on scientists in general. :) Pickering’s excellent “The one culture?” (and way before that Gilbert and Mulkay’s “Opening Pandora’s Box”) show that while there are some scientists that indeed show this kind of epistemological naivet�, there is also a large contingent that takes a much more nuanced approach.
    P.S. Fully agreed on Hacking, not so sure about Haack. :)

  15. #15 revere
    December 26, 2006

    Ken: I don’t think we disagree, although we have differing emphases. Regarding Popper, insofar as a scientist has any thought about the Demarcation Problem (I’m excepting physicists here because they have had to grapple with quantum mechanics, now string theory and much else to upset a naive realist) it either comes out as “testability” or Popperism, usually the latter.

    Regarding humility, I now many CAM advocates are anything but humble. But I wasn’t addressing them. As I said, CAM isn’t an interest of mine. I was addressing scientists and there I don’t find much humility. As for Susan Haack, she and I disagree on much, but I find here delightful and thought provoking. Her latest book (Defending Science, within Reason) has much to recommend it, IMO.

  16. #16 Ken Camargo
    December 27, 2006

    Hi,
    Indeed, we don’t disagree. I’ll check Haak’s book – I’ll come back in flames if I don’t like it, tho. :)
    As for the scientists, there I disagree a bit. Those two references (and another one that later came to my mind, Karen Knorr-Cetina’s “Epistemic Cultures”) have data either from interviews and ethnographic observation or actual papers from scientists (Pickering’s book), and there’s a lot more variation that that.
    I’d go with Kuhn on this one; as a general rule, scientists don’t care much about philosophy, except during what he dubs paradigm crises. I think that was the case of Epidemiology in the eighties, with Carol Buck’s call for a “Popperian Epidemiology”, and I think we can safely say that it was left behind. Susser and Krieger (among others) have been writing epistemological papers that are light-years away from that (and far more interesting IMHO).
    Anyway, I’m getting into an associate editorship in our area and I would like to count with your inputs on that in the future. Deal? :)

  17. #17 Ken Camargo
    December 27, 2006

    Me again – I reread your last post, and there’s a crucial bit there that I didn’t fully take into account: “insofar as a scientist has any thought about the Demarcation Problem”. I guess you are right. What I’d say is that they usually don’t.

  18. #18 Mark Crislip
    January 16, 2007

    Being, of course, insolent, I search the web using my name and quackcast and was lead to this site.
    Whoa.
    This is a level of intellectual discourse about SCAMS far beyond my usual name calling and sarcastic asides.

    Couple issues:

    A) I have to go back and clarify a podcast: I do not think there is a placebo effect outside of a very small effect for pain. There is no data to suggest that activity doing nothing has more effect than doing nothing.
    N Engl J Med 2001;344:1594-602.)

    IS THE PLACEBO POWERLESS? An Analysis of Clinical Trials Comparing Placebo with No Treatment.

    The answer is yep.

    B) What I don’t see in either discussion is moral outrage and responsibility about SCAMS.

    I work all day every day in the hospital taking care of acutely ill people that are actively trying to die.
    I am responsible: it is not the med student, resident or the fellow, and I don’t go off service after 4 weeks and turn the patient over to the next attending. The buck stops with me.
    People live and die by my (and my colleagues) direct decisions and the job is impossible.
    The information I have to know seems infinite.
    The data upon which I make decisions is always flawed: the studies, the history, the physical, the labs, the xrays: Is a negative result a true negative. Is the history correct?
    Is it a common disease or am I about to be blind-sided by some weird infection. Is it some unusually resistant bacteria?
    Often it seems I am dealing with probably waves rather than defined diseases.
    I know all too well that I can do everything right, and the patient dies.

    I have no idea what “The process of healing as a whole, however, is much more complex than just administering herbal remedies, involving an etiology of soul loss and harmonization of the patient’s social relations. It is a ritual process of ‘reintegrating and reoriginating’” means.
    I have to figure out what your infection is and kill it, often with a best guess, before it kills you.

    My job is simple in its conception: me find bug, me kill bug, me go home; impossible in its conception.

    These quacks have no responsibility and what they do kills. Yeah. I know. So does modern medicine. But what we do is better and safer than the natural history of disease.

    I always tell patient that there are not good solutions, there are less bad solutions. That concept is lost on most patients: medicine is dangerous. It is (hopefully) less dangerous that whatever ails you.

    How many patients have you been responsible for who have gone from zero to dead from meningococcus? Me? Too many. And if you have, then how can you treat homeopathic “vaccines” a with anything but contempt. and outrage. Or the patient who gets nec fasc from the acupuncture, or takes energy therapy instead of chemo for their Hodgkin’s, or organizations who are against condoms, or vaccines. etc etc etc.

    Or any other quack nostrum. Use them and die.

    I don’t deal with epistemology, I deal with mortality and morbidity. I can’t be respectful of ignorance and stupidity and irrationality because it kills and harms people. Real people.
    Not thereoritical people or some demographic. When they stop breathing and the life goes out of their eyes, I am one of the people who are there.

    The core difference is “Let me say again, I don’t know if acupuncture works or not, nor do I much care.” I do care and I need to know, because tomorrow my patients life and health may hang in the balance.

    c) The characterization of modern medicine, at least as it is practiced in Portland Oregon, seems completely out of touch with the practice of medicine as I know it. And then he uses an anecdote of the orthopedic surgeon. Do you have it documented that the surgeon didn;t see your son? Thanks to the wonders of modern pharmacy, many of my orthopedic consults have zero memory of my visits in the 48 hours they were in the hospital. If it is true that “He never saw the surgeon and never had the procedure or the condition explained to him.” I am dumbfounded at both the surgeon (PAR has to be done and documented by law before any procedure, although again the data suggests that many patients neither hear nor remember the PAR) and that someone would allow an operation to be performed on them without knowing the what and the why.

    d “Yet he doesn’t demand compelling evidence for efficacy for the many things surgeons and others do for which he has one or more (possibly contradictory) plausible scientific explanations.” There in lies the problem with the messy messy practice of medicine. Depending of the problem at hand you have to decide what to do based on everything from biologic plausibility to RCTC. I would love to have the latter, but when I have a procine valve infected with Candida glabrata I am going to be rather limited in the data I have to back up my decisions. Welcome to the real world. But unlike SCAMS, it is based on the real world as best we know it. I am not going to treat the valve with chiropractic.

    e) “The history of science is littered with examples of things that “shouldn’t work” or “shouldn’t happen”
    True. I suppose. In my years of practice, none of the shouldn’t haves or shouldn’t happen were based on irrational belief systems. When I was a medical student, ulcers were due to stress, now they are due to helicobacter. While it “shouldn’t work” or “shouldn’t happen”, unlike SCAMS, there was no fundamental reason helicobacter should not cause ulcer; it wasn;t totally implausible. Most of SCAM violate EVERYTHING we know about the physical world. EVERYTHING. Do you have a medical example in the last 50 years where one of these supernatural shouldn;t haves became true?

    f) “slid over the cases where there is no demonstration of efficacy in conventional medicine, perhaps the major category.” I can’t think of an example in my (hospital based) practice where this is true. What do I do on a daily basis that has no demonstration of efficacy? I know you can come up with a good examples (pleural) since it is a major catagory.

    g) . I’m just asking, as a non-surgeon, for a surgeon to tell me what justifies a lot of the procedures he and his colleagues do since they are, by his own admission, untested by his gold standard. He doesn’t say whether many are actually tested in any way, although I believe many aren’t. What are Orac’s standards beyond his gold standard or some good observational study design? Is it clinical experience? Is it an inference from some known mechanism? And when there are options, i.e., different ways to carry out a procedure or even a choice between medical or surgical management, what justifies his choice?”
    Are you talking open heart? valve replacement? appy? I am often aggravated by the variability in approach from surgeon to surgeon and understand the vagaries of “clinical judgement”; which one do you have in mind?

    h) “Obviously there is a well-documented placebo effect, however.” Obvious? Well documented? I don’t think so based on my reading of a less than clear literature. See the review above as a start.

    i) “a confusion between whether something does work or not with whether the reason given for any efficacy makes sense to Orac in terms of his own understanding of what is allowable scientific explanation.” Again, if you are dealing, really dealing, with life and death, the only reliable standard you have is the scientific understanding of the world, for all its flaws.”

    j) “I think this is a very conventional view, and one to which I don’t necessarily object, but I feel compelled to make some observations about it. For example, it is a recipe for “in the box thinking” that is OK for everyday science but not very promising for innovative science.” You mean like taking care of sick people. Do you have a better conventional view I should take?

    “woo” and untested conventional practice are the same except that conventional practice doesn’t make “outlandish” claims about how it works.”

    People don’t get into airplanes based on alternative aerodynamics. I wonder why. Perhaps the conventional view, oh, I don;t know, has a better chance of not crashing.

    Do you really want me treat people based on the ‘Law of Similiars” or chi, or Reiki? Really. Truely?

    Medicine is an applied science with real world consequences. I am not trying to be innovative, I am trying to take care of sick people

    k) “But of course most aren’t tested, for one reason or another, and most doctors don’t even know whether they have been tested or not. We learned them in school and we keep doing them.” Really? Thats so not true. Got some data to back that up? As an expert in a medical sub specialty, what makes me an expert is my attempted mastery of the literature of my field. Wander onto the Good Sam wards for rounds and see the attending and residents quote , at various levels of sophistication, the medical literature , to support the practice of medicine.

    I could go on, but there is a rare snow fall in Portland and my 9 year old wants to go sledding.