Respectful Insolence

Well, I’m back.

Grant frenzy is over (for now), and I have a couple of weeks before the next cycle begins again. Well, actually, it’s more than that. The next big NIH grant deadlines are in October and November, but the Susan G. Komen Foundation grant notices just showed up in my e-mail the other day, and the deadlines for its preapplications are in early to mid-August. The fun never ends, and if the Army approves my preapplication for its Idea Award grant application I’ll have a full application to write in August too. It’s times like these when I ask myself why it is exactly that I do this again.

Oh, yes. It’s because I love science so much.

Actually, it’s true. I do love science, which is one reason why I get so agitated when I see it abused. Since I also love medicine, it agitates me even more to see both science and medicine abused, which is what I see happening with the infiltration of quackademic medicine into what were once bastions of evidence- and science-based medicine. It’s also part of the reason why I got so annoyed by the outright apologia for quackademic medicine that I saw in David Freedman’s recent Atlantic article The Triumph of New-Age Medicine. As you might recall, a couple of weeks ago I made my displeasure known and then did it again after Mr. Freedman went on the counterattack against his critics.

While I’ve been…preoccupied trying to keep my lab in existence another few years, I noticed that there’s a “debate” at The Atlantic about Freedman’s article entitled Fix or Fraud? You can tell from the very beginning exactly which side of the issue The Atlantic comes down on by its choice of debaters. (Hint: It’s not “fraud.”) The lineup is stacked with a veritable pantheon of “heavy hitters” in the alt-med movement, all arrayed initially against Steve Salzberg, who appears to have agreed to take on the role of the token skeptic as he correctly entitled his rebuttal A “triumph” of hype over reality. Later, David Colquhoun was added to the mix and contributed a post entitled America, Land of the Health Hucksters, but I strongly suspect that this was a result of complaints about how blatantly, obviously, and unabashedly stacked against skeptics the first lineup was. Besides the author of The Atlantic‘s paean to alt-med, arrayed against Salzberg and Colqhoun are:

Then David Freedman himself chimes in with a post entitled: What’s Eating the Small, Loud Band of Alt-Med Critics?

Since there’s so much here, I can’t deal with it all, even writing an Orac-length post. Even though I wanted to comment one more time, I don’t want to comment multiple times. Consequently, for the posts by Drs. Briggs and Weil, I’ll refer you to what is an excellent deconstruction of the nonsense contained therein (in the second part of the post). I’ll then deal briefly with each of the last few posts, because they’re all very telling in their own ways.

But first, let’s deal with the perpetrator of this mass of apologia for pseudoscience, Mr. Freedman. His little rant, apparently provoked by David Colquhoun’s excellent bit of no-holds-barred, take-no-prisoners blogging, is an obvious bit of “framing” and not in a good way. All I can say is that Mr. has really thin skin. Paper thin. Cell membrane thin. Really, really thin:

I give credit to the enthusiasm and passion of the small band of deeply anti-alternative-medicine warriors who have voiced their displeasure with my article. And let’s be clear, this is a very small band. As I think was made plain in my article, most mainstream physicians and physician researchers pretty much agree with my basic argument.

Once again, one wonders how Mr. Freedman knows that “most mainstream physicians and physician researchers pretty much agree” with his basic argument. Unless he’s done a large, well-designed poll, he can’t possibly say that. Even if he interviewed 100 physicians and researchers, that is a very small fraction of all the physicians out there, and it’s not even a scientific sampling. It’s a biased sample. After all, Mr. Freedman was doing a story about alternative medicine, and where do you find “experts” on alternative medicine? At centers of quackademic medicine. And who are the faculty at centers of quackademic medicine? Believers in alt-med, of course, believers like Dr. Brian Berman, the acupuncture aficionado profiled.

He also makes much of how he is supposedly in “total agreement” with major points made by Colquhoun, Salzberg, Novella, and myself:

I’d hate myself, if it weren’t for the fact that I don’t do any of this in the article. Rather, I point out high up in the piece, and with no bones about it, that science has pretty clearly shown that the core treatments of alternative medicine don’t provide the direct physical effects that they are claimed to provide by practitioners. They work via the placebo effect. Now could someone please explain to me how it is that I could be defending pseudoscience in an article in which I so clearly say it’s pseudoscience, and that it doesn’t provide the claimed benefits? I do suggest there’s a placebo benefit — but so do my critics. We’re in perfect agreement.

At best Freedman is being clueless here, at worst disingenuous. While it is true that Mr. Freedman sort of agreed with the skeptics, it’s how he did it that makes the difference. First, he sets up his entire premise as a false equivalence between science-based medicine and alt-med quackery. Alt-med quackery is placebo, but science-based medicine often doesn’t work and there is placebo effect. Of course, in studying science-based treatments, we try very hard to control for nonspecific effects and placebo effects because we want to know how much real physiological effects due to the intervention provide a benefit. In alt-med, placebo effects are the whole point, and the rationale for the treatments are wrapped in mystical, magical mumbo-jumbo. Basically, the whole premise of Freedman’s article boiled down to arguing that, if real doctors can’t provide the time and empathy patients crave, then maybe we should let the quacks to it.

He is, however, very good at painting his critics as a small band of dogmatic, unreasoning, ideologically motivated believers in his misnamed “scienceology” (or, as creationists would call it, scientism). Sound familiar? It’s the same sort of framing frequently used to marginalize atheists and agnostics. Since there is heavy overlap between skeptics and atheists and agnostics, this is not surprising. One wonders if David Freedman is taking lessons from Deepak Chopra or Michael Egnor.

But on to the other respondents. I won’t say that much about Dean Ornish’s post, mainly because I’ve blogged extensively about Dr. Ornish before. His post is a masterful example of the alt-med/CAM/integrative medicine phenomenon known as the “bait and switch.” Consistent with that, Ornish harps on his diet and lifestyle changes, even though diet and lifestyle changes are not in any way “alternative.” He also brags about his research that found changes in gene expression in the prostate in response to his diet, a study that I didn’t find particularly impressive. At the very least, it was far overblown and Ornish drew exaggerated conclusions from it that are not supported by his data, as he touted his paper on telomerase, another paper I didn’t find nearly as impressive as CAM advocates do.

I was, as you might imagine, underwhelmed.

Next up is Dr. Guarneri. Her entire article can be boiled down to this:

So why are we arguing over whether or not acupuncture is a placebo? We have three licensed acupuncturists and two physician acupuncturists at The Scripps Center for Integrative Medicine. I can cite patient after patient who has received benefit from our acupuncture program. And in regard to Dr. Salzberg’s post, I have never seen a punctured lung or infection as a result of an acupuncture treatment. While I am sure complications can occur, they are certainly much less common than the hospital-acquired infections I saw as an interventional cardiologist.

“I can cite patient after patient.” Yup, that’s anecdotal evidence being touted over science and clinical trials. Note how Dr. Guarneri doesn’t cite a single well-designed, randomized, double-blind clinical trial of acupuncture. She’s seen it work (or thinks she’s seen it work), and to her that is enough, just like our favorite apologist for the anti-vaccine movement, Dr. Jay Gordon, has seen children become autistic after vaccination (or thought he’s seen children become autistic after vaccination), and that’s enough for him. No need for clinical trials, epidemiology, or anything else for that matter. It’s the triumph of “personal clinical experience,” which can be highly misleading, over science. Remember, to paraphrase Richard Feyneman, you must not be fooled, and you are the easiest one to fool. Science is nothing more than a system designed to minimize the chances of being fooled or making a biased interpretation of observations.

The rest of Dr. Guarneri’s post is similar to Ornish’s in that she cites some of Ornish’s work. She then parrots Freedman by complaining about shortcomings of “conventional” medicine and concludes by cherry picking studies supporting the benefits of diet and lifestyle, thus completing the circle and coming back to the classic alt-med “bait and switch.”

In the next post, Vasant Lad sings the praises of Ayurvedic medicine, which is a lot like traditional Chinese medicine in that it is derived from a prescientific, vitalistic, religious misunderstanding of how the body works and what causes disease. Not that that stops Lad from making this evidence-free assertion:

Ayurveda is a safe alternative approach, a medical system that focuses on preventing disease and treating its root causes. Ayurveda provides specific advice on proper diet and lifestyle, as well as cleansing and detoxification programs. And unlike modern allopathic drugs, Ayurvedic treatments are tailored to the specific constitution (prakruti) and imbalances (vikruti) of each individual person. Following these guidelines can help prevent future heart attacks, stroke paralysis, or even cancer. It is also useful for chronic conditions such as rheumatoid arthritis and sciatica, improving quality of life in a way that modern medicine has not managed to do.

One notes the similarities between these “imbalances” to the “Western” prescientific concept of “balancing the four humors.” Instead of science as a basis for medicine, Lad appeals to ancient knowledge:

As the Atlantic article points out, modern medicine relies on clinical trials to test the effectiveness of a drug. The Ayurvedic approach is a bit different. In addition to a history of developing and testing new substances, Ayurveda relies on its own pharmacological “database,” recorded in ancient texts such as the Charaka Samhita. Every herb we use has logic behind it, based upon the qualities of the herb and its effects as it passes through the digestive tract. This action is not placebo; it is based upon a centuries-old understanding of how an individual’s constitution interacts with a specific substance.

In other words, there’s no science here. Only appeals to ancient prescientific beliefs and a plaintive claim that Ayurvedic medicine is not placebo.

The final panelist, Reid Blackwelder, doesn’t so much appeal to ancient knowledge as much as joining in the chorus of CAMsters who try to paint “conventional” medicine as dangerous (citing without context the estimates of death and destruction that allegedly occur as a consequence of the use of prescription drugs. He then adds the typical appeal to placebo effects, striving against science, as Freedman and others have done, to make the weakness of alternative medicine (that the vast majority of its modalities have no specific effects, that they are in reality placeboes) into its strength, topping it off with the classic bait and switch.

In the end, The Atlantic has done its readers a grave disservice. First, it published the poorly argued, biased apologia for pseudoscience that was Freedman’s original article. Then it compounded its original error by holding a pseudodebate in which the deck was hopelessly stacked against defenders of science-based medicine, lining up practically every heavy hitter in the world of woo other than Deepak Chopra and Dr. Oz against Steve Salzberg and David Colqhoun, while allowing David Freedman to paint his critics as an angry, irrational, hate-filled tiny minority, the better to dismiss them as irrelevant. The classic CAM “bait and switch” is not a valid argument, nor are diet and lifestyle interventions “alternative.” Worse, the poor, misunderstood placebo effect has become an all-purpose excuse to justify the infiltration of quackery into institutions of science-based medicine.

Comments

  1. #1 Emil Karlsson
    June 30, 2011

    Can you dish out some insolence on Jerry Coyne’s claims about medical psychiatry? It looks like it is like the Coby situation all over again.

    http://whyevolutionistrue.wordpress.com/2011/06/25/is-medical-psychatry-a-scam/

  2. #2 bsk
    June 30, 2011

    Seconded.

  3. #3 Dangerous Bacon
    June 30, 2011

    Freedman: “What’s Eating the Small, Loud Band of Alt-Med Critics?…I give credit to the enthusiasm and passion of the small band of deeply anti-alternative-medicine warriors who have voiced their displeasure with my article. And let’s be clear, this is a very small band.”

    Poor Mr. Freedman is working overtime to convince readers that hardly anyone disagrees with his support of woo. If virtually everyone is in accord that quackery is terrific, one wonders why he and the Atlantic bother with these articles attacking evidence-based medicine?

    Except he knows the people who are really making things happen in medicine have no use for the woo mindset.

    If the Atlantic really wants a degree of balance in its “debate”, it can ask Dr. Edzard Ernst to weigh in – a man with fine academic credentials who’s published extensively on “alternative” medicine (and found it severely wanting).

    One wonders how many folks over at Atlantic have bought heavily into “toxin cleanses”, reiki, homeopathy and other forms of woo and are now laboring mightily to convince themselves that they’re at the forefront of a revolution in medicine, instead of the latest in a parade of marks who’ve wasted time and money on quackery.

  4. #4 Marry Me, Mindy
    June 30, 2011

    Ornish harps on his diet and lifestyle changes, even though diet and lifestyle changes are not in any way “alternative.”

    In principle, no, but in practice, what they are talking about absolutely IS alterative. When wootastic folk talk about “diet” changes, they aren’t just talking about moderate portions and more fruits, veggies, and fish and less sugar and fat, etc. Their versions of “diet” changes include baseless idiocies like gluten-free, vegan diets and stacks of supplements as the starting point for everything. There is a discussion on SkepticalOB right now about people who think that drinking raspberry tea can change your Rh- bloodtype to Rh+ (there are actually people who believe that!). And “lifestyle” doesn’t mean exercise, but things like yoga and daily enemas. Sure, there is real benefit to yoga (as a stress reliever) but it isn’t unique in that regard.

    So yes, while modern medicine absolutely is concerned about proper nutrition and lifestyle, that is not necessarily the same thing that woomeisters are talking about when they talk about “diet and lifestyle.”

    Remember, the whole “Gonzalez” procedure for curing cancer is nothing but a change in diet and lifestyle. And it’s all bullshit.

  5. #5 Jojo
    June 30, 2011

    Rather, I point out high up in the piece, and with no bones about it, that science has pretty clearly shown that the core treatments of alternative medicine don’t provide the direct physical effects that they are claimed to provide by practitioners.

    This is what bothers me the most about Freedman’s stance. He knows it doesn’t work any more than placebo, but he still thinks it’s all full of awesome. He may have no problem being lied to and being charged for treatments that don’t work, but I certainly do. Does he not care about ethics? Is lying and taking people’s money OK if it makes them feel all warm and fuzzy? Maybe it’s not that bad when it’s for subjective problems or self limiting conditions, but where do you draw the line? It’s easy to say alt med is fine for a cold, but what about for cancer? If he doesn’t think it’s OK for treatment of cancer, then I’d like him to explain exactly when alt med is OK. Define when it is and isn’t OK. I think he would find that damn near impossible.

    I’ll also second Pablo’s (Marry me, Mindy) point about what the woo-sters consider diet and life style changes. It’s not just exercise and good nutrition. It goes into very ritualistic practices including serious dietary restrictions and poor advice. (Replace your HFCS with Agave juice! Even though there is significantly more fructose in agave juice.)

    Finally, I’ll third the 1st and second comments. Jerry’s article really is quite scary.

  6. #6 Calli Arcale
    June 30, 2011

    “Ayurveda is a safe alternative approach”

    Which is a very interesting claim for him to make about a modality which actually prescribes *lead* as a medicine. It is clear to me that not only does Freedman not really know much about these treatments and the patients who receive them, but he’s not really very interested in learning more. He’s in good company; most of the practitioners are that way also. Why find out if it works when you already think it does? Why even find out *how* it works?

    Freedman’s biggest mistake, though, is in thinking that the placebo effect is something real. If it were true that you could really make people actually better with a placebo, that would be wonderful. But that’s not really what’s going on, 9 times out of 10. (And the remaining 1 time out of 10, the patient wasn’t all that sick to begin with and just was feeling stressed. Lies aren’t needed to treat stress.) 9 times out of 10, the placebo effect is no effect at all — it’s either perceiving improvement where there is none, or wrongly attributing improvement to a therapy that had nothing to do with it.

    Freedman doesn’t see a problem with that. This is not because he is stupid. He isn’t stupid. Most people who believe in woo are also not stupid. What he is is closed-minded. He has come to a conclusion, and he is completely uninterested in examining it to determine whether or not it is true. It is not stupidity at work but a depressingly incurious nature.

    If he was more curious, he’d know that people have died from acupuncture. People have required chelation to save their lives after receiving ayurvedic medicine. (Usually, this is reported as “lead-tainted medicine”, which is a shame since it means people think it was an accident. In fact, the lead was in the medicine intentionally. It *is* the medicine.) People have died by taking homeopathy instead of seeing a doctor, allowing their condition to deteriorate to where they were beyond help. People have died from chiropractic, which while it *can* be safe, isn’t always, and the chiropractic colleges have shockingly low standards which probably contribute — there have been lawsuits brought by chiropractors who discovered how poor their training had been and wanted their tuition back. I could go on, but it’s simpler to just point out whatstheharm.net

    The worst part, to me? Freedman continues to believe that we are the dogmatic ones, that we are the ones who are refusing to look at evidence. Yet he is the one staunchly holding a view in defiance of the evidence. Meanwhile, we are all too happy to look at evidence, and if it seems acupuncture could be beneficial, I’d sign up myself! But I need more than just “it worked for me”. Testimonials can be suborned, and personal experience is very unreliable. It worked for you — great! Now how do I tell whether it will work for me? The answer is science, and it’s not difficult to do. But the promoters of woo are completely disinterested in it. They’ll do some token science, and they’ll even author a few studies which, frankly, tend to be worse than even the most biased pharmaceutical study for an FDA application — they tend to be designed for success, not for truth, and they tend to have no conception of what the placebo effect actually means (hence why studies which find effect equivalent to placebo are heralded as great successes for homeopathy and acupuncture, while scientists shake their heads in dismay).

  7. #7 Calli Arcale
    June 30, 2011

    Jojo:

    Replace your HFCS with Agave juice! Even though there is significantly more fructose in agave juice.

    I’ve bought agave juice; the amount of fructose varies, mostly based on what type you’re getting and how it was processed. My daughter loves it. It tastes similar to maple syrup. It’s thicker, though, which is nice. My husband can’t stand real maple syrup — it’s too runny, in his opinion. (He’s comparing it to Mrs Butterworth, which is his preferred brand.) So the agave has been a fair compromise.

    But yeah, they often tout themselves as being “low glycemic index!” despite the fact that if you look at the label, it’s got just as much sugar as honey or corn syrup. Perhaps something chemically makes it slightly less bad, but I seriously doubt it would really make any difference. Sort of like using sea salt instead of rock salt on the basis that it’s got less sodium. Yes, it does have less sodium, but the difference is so trivial (and we pour on so much of it) that it’s really not gonna make a whole lotta difference.

  8. #8 Denice Walter
    June 30, 2011

    Whenever I despair ( and I do) about CAM’s ascent, I try to remember that we have the means of *testing* ideas rather than merely talking about them incessantly. Everything comes out in the wash: nonsense will not stand up to scrutiny whether it is through reasoned discussion, investigation, or by studies. Reality will out… eventually.

    If you scan the history of psychology, you will encounter bizarre theories and ridiculous ideas presented as ways of explaining observed human phenonmena. Theories about the causation of SMI alone hold many extravagant- and often laughable wonders- none of them “held water” and eventually they came to be regarded as mere curiosities from our past. Swept away from consideration. I’ve mentioned Burt’s heritability results: they too are no longer mainstream science, although they once were popular enough to influence how the school system was structured in the UK. Also swept away by the cleansing oceanic wave of investigation and non-replication. Unreal ideas don’t *work* in the real world. Sooner or later, people discover this.

    Every field can provide similar examples. What we are *really* addressing here is how the popular media *handles* the current state of science. CAM apologia, woo-ful websites, or watching Dr Oz on TV cements the general public’s un-schooled notions, which they also mirror recursively. It sells adsvertisement.

    What I really fear is that this will take virtually forever: so much wasted time, effort, and money on nonsense. It makes me cringe. I do not see any magazine or media outlet doing the equivalent what Collier’s did at the turn of the past century when it demolished the lucrative patent medicine scam. We’re it. I truly believe that there is a long battle ahead for supporters of reality, but consider what our predecessors had to deal with only a little more than a hundred years ago: spiritualism and seances were all the rage in capitals of finance and learning, like London and New York.

  9. #9 Matthew Cline
    June 30, 2011

    There is a discussion on SkepticalOB right now about people who think that drinking raspberry tea can change your Rh- bloodtype to Rh+ (there are actually people who believe that!).

    *headdesk*

    So, what, is the logic something like this?

    1) A pregnant woman being Rh- can cause problems for the the fetus.
    2) If something about a pregnant woman can cause problems for the fetus, it must be a health problem.
    3) If being Rh- is a health problem, then you must be able to become Rh+ by getting more healthy.

    *blah*

    Hmmm, interesting, there’s an article hosted on vaccinetruth.org which calls Rhogam a vaccine. If you’re going to be against vaccines, shouldn’t you know that Rhogam isn’t a vaccine?

  10. #10 Marilyn Mann
    June 30, 2011

    Here’s an example of harm from acupuncture:

    http://www.cmaj.ca/content/early/2011/06/27/cmaj.110128

  11. #11 Anton P. Nym
    June 30, 2011

    Freedman’s biggest mistake, though, is in thinking that the placebo effect is something real.

    I’d argue that he makes a bigger mistake; even after acknowledging that alt-med relies on the placebo effect, he still supports delivering them as placebos that are vastly more expensive and time-consuming than science-based placebos. Saline shots and sugar pills also induce the placebo effect, at vastly lower costs than all of the “alternative” modalities offered and with vastly fewer risks than most. Even if you grant Freedman’s premise, he’s still wrong; people are being hurt by alternative medicine, even if only in their wallets.

    (And I don’t grant his premise. Medicine doesn’t get to be called medicine in these parts unless it beats the placebo effect… so, by definition, it’s better than PlaceboCare.)

    — Steve

  12. #12 Edith Prickly
    June 30, 2011

    One wonders how many folks over at Atlantic have bought heavily into “toxin cleanses”, reiki, homeopathy and other forms of woo and are now laboring mightily to convince themselves that they’re at the forefront of a revolution in medicine, instead of the latest in a parade of marks who’ve wasted time and money on quackery.

    I suspect you’re right about this. A lot of these overpaid media clowns have nothing better to do with their money and like to think they’re out on the cutting edge when in fact they’re just suck-ups and fad followers. I mean, if Arianna Huffington believes in a woo, there must be something to it, right?

  13. #13 Jojo
    June 30, 2011

    @Calli Arcale – Yes. It’s not the agave juice I have a problem with. It’s the “HFCS is EVIL” from people who are pouring sugar in their coffee, honey in their tea, and agave juice in their baked goods that I have a problem with. This is a common attitude among my liberal mom friends. They fall for the woo about HFCS while completely missing the point that it might be healthier to consider controlling every source of sugar in their diets. One woman, who is already on a vegan diet, has now switched to a raw vegan diet because the vegan diet wasn’t giving her the results she wanted. Perfect examples of woo nutrition that may not be good nutrition.

  14. #14 Edith Prickly
    June 30, 2011

    One wonders how many folks over at Atlantic have bought heavily into “toxin cleanses”, reiki, homeopathy and other forms of woo and are now laboring mightily to convince themselves that they’re at the forefront of a revolution in medicine, instead of the latest in a parade of marks who’ve wasted time and money on quackery.

    I suspect you’re right about this. A lot of these overpaid media clowns have nothing better to do with their money and like to think they’re out on the cutting edge when in fact they’re just suck-ups and fad followers. I mean, if Arianna Huffington believes in a woo, there must be something to it, right?

  15. #15 Dangerous Bacon
    June 30, 2011

    “I do not see any magazine or media outlet doing the equivalent what Collier’s did at the turn of the past century when it demolished the lucrative patent medicine scam.”

    This is a perceptive comment. Even though mainstream medicine in those days was limited in what it could do for patients, Collier’s still recognized worse dangers in reliance on quack remedies that often contained substantial alcohol and opiates, creating addicts. It’s sad that in order to gain readership (or more realistically, hoping to hold onto a smidgen of its declining readership base), Atlantic is betraying consumers rather than educating and warning them about quackery.

    Incidentally, we just had another case locally of a patient who had her neck adjusted by a chiropractor and developed paralysis. Given the notable lack of evidence that routine neck cracking does patients any good, it’s amazing that chiropractic still condones this practice.

  16. #16 rob
    June 30, 2011

    Steve Martin SNL monologue from season 4, episode 4:

    …[ seriously ] But I quit that! I’ve quit ALL drugs. Well… let me say one thing: I twisted my ankle this morning, and I was in quite a bit of pain… so I went to the doctor, and I asked him to give me some pain pills. And he didn’t want to do it, but I talked him into it. So he gave me some pills — and I shouldn’t have done this, but I took some about an hour before the show tonight, and right now… I am high… as a KITE! [ audience cheers ] I mean, it is unbelievable! And I would NEVER say this to you people, but, in this case: if you EVER get a chance, to take these drugs… DO IT! They’re called… [ he glances from side-to-side cautiously ] Placebos! I mean, I’m thinking that right now I have NO idea where I am at all! It is WILD! Placebo!”

  17. #17 Denice Walter
    June 30, 2011

    @ Dangerous Bacon:

    I thank you sincerely, kind sir : it means a great deal coming from you.

    That’s why I follow pseudo-science ( since January 2000) and have more recently applied my rather odd skill-set and complicated education towards communicating my ideas.

  18. #18 David H. Freedman
    June 30, 2011

    I’d like to make a small point, for what it’s worth: What I mean by “scienceology” is actually not, contrary what Orac suggests, what is usually meant by “scientism.” It’s probably my fault, for not better explaining what I meant. Scientism is usually taken to mean that science is being applied to an issue where it should not be applied, or where it can not be expected to provide answers, perhaps even in principle. I believe science applies to everything, though of course it often struggles to give us right answers (as I’m sure Orac will agree, unless he’s been sitting on a cure for cancer).

    What I mean by scienceology is in some ways the opposite of scientism. I define scienceology (and I get to define it, because I made it up) as acting as if (and presumably believing that) one is applying science-like thinking when one is actually applying religion-like thinking. I characterize science-like thinking as being deeply interested in figuring out where one is going wrong and what one is missing, in combing through all available evidence and even in actively hunting down new evidence to look for where such evidence might refute or suggest a problem with or alternative to one’s operating theories, in recognizing that there may be (and in fact almost certainly is) missing or distorted evidence in play that may be leading one astray, in carefully considering new and different hypotheses to see how they might be able to fit the evidence as well as one’s operating theory, in trying as best one can to put aside one’s biases in determining whether one can feel confident one is on the right track, and in general in being prepared to at least modify one’s beliefs and working hypotheses.

    I characterize religion-like thinking as being absolutely certain that one has hit on pure truth, that the evidence supporting it is perfectly solid, that the evidence that might be held to refute it is weak or flawed, that anyone who disagrees simply doesn’t get it or is highly biased, and that any arguments or evidence presented to counter one’s beliefs must be (supposedly) demolished or ignored so that no trace remains that might prompt reconsideration in the least of any aspect of one’s beliefs.

    Obviously determining who should be labeled a scienceologist is a subjective affair, but here’s one little field test that I find helpful: When a proponent of one particular view or theory in a presumably scientific debate consistently fails to yield any ground on any points, or concede any possible truths to any aspect of the opponent’s views, I fear I’m dealing with scienceology. After all, we live in a complex world, and the chances that one is right about all aspects of any non-trivial issue are minute. Only religion-like faith invites and sustains belief that one has it completely right in every way, or so I would argue. Succumbing to scienceology doesn’t necessarily mean one is wrong, but in my opinion it means if one is right, one is just lucky, because one has closed one’s mind to all routes to discovery of being wrong.

    I most definitely do not feel you folks are engaging in scientism in criticizing my article. I heartily agree with you that science should, at least in principle, be able to settle the question of whether there are measurable patient benefits to alternative medicine when compared to mainstream medicine, even if the core treatments of alternative medicine work no better than placebo.

  19. #19 Jojo
    June 30, 2011

    Obviously determining who should be labeled a scienceologist is a subjective affair, but here’s one little field test that I find helpful: When a proponent of one particular view or theory in a presumably scientific debate consistently fails to yield any ground on any points, or concede any possible truths to any aspect of the opponent’s views, I fear I’m dealing with scienceology.

    Based on my reading, while I agree that this does exist somewhat in medicine, alt med is absolutely oozing with scienceologists.

  20. #20 Anton P. Nym
    June 30, 2011

    When a proponent of one particular view or theory in a presumably scientific debate consistently fails to yield any ground on any points, or concede any possible truths to any aspect of the opponent’s views, I fear I’m dealing with scienceology. After all, we live in a complex world, and the chances that one is right about all aspects of any non-trivial issue are minute.

    And that’s where you go wrong, Mr. Freedman. There are positions held without merit, that have no basis in fact beyond wistful thinking (or indeed, in some cases, willful denial of impartial observations) and therefor have nothing to grant.

    What does one say in an argument with people who deny the validity of empirical experience, for example? What factual basis is there for agreement between a scientist studying quantum mechanics and Deepak Chopra? Exactly how much merit should one grant to a position that has no basis in logic, that uses a wall of pseudoscientific terminology to cover over that lack?

    If I grant anything to “alternative medicine” it’s that it’s an interesting window into the cognative biases of our brains. Beyond that, it’s “put up or shut up” and meet, at the minimum, the standard of proof we set for every other form of treatment before earning my respect.

    If that’s scienceology, then so be it… because it’s the same scienceology that brought about the machinery that supports the lifestyle we live today.

    — Steve

  21. #21 Robert B
    June 30, 2011

    Ayurvedic isn’t always placebo, it also includes massive doses of heavy metals (as in actually toxic) that aren’t dangerous because they have been prayed at.

    Yeah. Thats gonna work.

  22. #22 William M. London
    June 30, 2011

    Freedman doesn’t appear to recognize or have acknowledged:

    1. We’ve heard his arguments and identified the fallacies many times before.
    2. Some of the criticism he has received is for what he has just directed to Orac and labeled as “scienceology.” It’s time for him to admit where he went wrong in his piece to pull himself out of his own “scienceology.”
    3. He may be fooling himself with the notion that taking a middle-ground position makes one reasonable and likely to be right.
    4. What he praises about “alternative” practitioners are attributes indistinguishable from what con-artists offer.
    5. He fails to closely examine how much of what is attributed to the placebo effect is not due to changes in physiology or pathology, but due to demand characteristics and other psychological triggers leading to favorable self-reporting. That’s why con-artists are very good at eliciting favorable self-reports from their marks. And attributed to Ben Franklin: “There are no greater liars in the world than quacks–except for their patients.” Patients lie to themselves–wishful thinking and cognitive dissonance will do that–and that leads many to give more favorable self-reports than they would without psychological influences.
    6. True placebo effects are not very dependable in practice. Please acknowledge this Mr. Freedman.
    7. There are many more informed critics of “CAM” he could have interviewed even though he has written that he had trouble finding them. Apparently, in his search for experts, he had difficulty “figuring out where one is going wrong and what one is missing, in combing through all available evidence and even in actively hunting down” experts.

  23. #23 David H. Freedman
    June 30, 2011

    I agree! Alt med is plagued with scienceology. That’s why I stipulated high up in my article that the treatments don’t work better than placebo–to short-circuit the whole tiresome argument over the direct physical effectiveness (as opposed to placebo effectiveness, which no one disputes) of these treatments. But I honestly have been taken largely by surprise by the scienceology that I think is rampant in this community. The two extreme camps sound almost exactly alike to me–the most aggressive alt-med proponents claiming that homeopathic (for example) remedies have been scientifically proven to work exactly as advertised, and this community claiming that any claims via any mechanism whatsoever for benefit to patients of alt med has been scientifically proven to be nonsense, with no one willing to bend an inch in the face of significant evidence and general mainstream-medical-science-practitioner agreement that neither camp has it right. Well, people know for sure what they know for sure, there’s no making a dent in it!

  24. #24 Robert B
    June 30, 2011

    Mr. Freeman,
    If alt med had the evidence to show that it was as good as real medicine, we wouldn’t be against it. That isn’t a religious or faith based response. It is a call for evidence as the driving factor in health care.

    We know that acupuncture does not work better than placebo based on trial after trial after trial. We don’t want to waste our time with things that don’t work, and actually having things like ethics gets in the way of us being supportive of hospitals and universities that we are or were involved with scamming patients out of their money for any reason. CAM is just one of those scams.

  25. #25 Dangerous Bacon
    June 30, 2011

    It’s nice that Mr. Freedman showed up to defend himself. Yes, he does get to provide a definition of his preferred term “scienceology”, but we also get to point out that it’s bunkum.

    Mr. Freedman sounds very much like the defenders of venerable forms of quackery like homeopathy and “toxin cleansing”, as well as more modern mythology like “vaccines cause autism”. The nonsense implicit in these modalities and beliefs has been refuted over and over and over again using solid reasoning and good evidence, but defenders of these beliefs continue to crank them out with dogged persistence (dogged dogmatism?), while simultaneously insisting that evidence-based medicine must perpetually entertain their delusions, or else be condemned as a “religion”.

    There is certainly willingness to consider new evidence and re-examine accepted practice in medicine (the FDA decision revoking the fast-track approval of Avastin for treating breast cancer is the latest example*), but the kicker is the requirement that there be evidence worth pursuing, not the same old repetitive drumbeat of anecdotes, fallacies and conspiracy theories that constitute defense of failed woo.

    *I would love to see Orac’s take on this issue, in particular the diatribes coming out of the Wall St. Journal proclaiming that Avastin’s lack of approval by the FDA signals the evils/ineffectiveness of the agency, and that we all should pay for drugs without demonstrated effectiveness, because we’re individuals and different from each other and what doesn’t work for some may work for others, etc. etc. (an argument frequently heard in support of woo-based therapies).

  26. #26 Uglyhip
    June 30, 2011

    Much of the high degree of certainty that so troubles David Freedman is, of course, an effect of dealing with the vast majority of CAM supporters, people who don’t think it’s a placebo.

    Of course, sometimes the advocates concede that okay, maybe it is. Which is when they switch gears into the line we’ve heard several times before, “Well, maybe the placebo effect is the thing alt med should deliver.” We feel quite comfortable dismising that outright, because for one thing, there’s nothing about scientific medicine that prevents the use of placebos (any more than lifestyle stuff).

    And isn’t it always better for the stuff to be handled by people who don’t have wildly wrong notions about how it works? A practitioner’s beliefs really do matter, and if they are, for example, vitalistic, that’s not going to get good results.

  27. #27 Calli Arcale
    June 30, 2011

    David Freedman:

    What I mean by scienceology is in some ways the opposite of scientism. I define scienceology (and I get to define it, because I made it up) as acting as if (and presumably believing that) one is applying science-like thinking when one is actually applying religion-like thinking.

    But that is *precisely* what is meant when the word “scientism” is commonly used. It sounds to me like you have redefined scientism to avoid the criticism that you’ve unnecessarily coined a new word, I’m afraid.

    Perhaps you don’t encounter many creationists and climate change deniers, but they use the word “scientism” to cast things like evolution and anthropogenic global warming as being just another religion in a scientific disguise. It’s a crucial element of their strategy, actually. And here, you are using that strategy against us.

    If this community sounds exactly like the alt med community, I think you’re not listening very carefully. You’re hearing what you expect to hear. This is probably why we haven’t heard you really respond to very many of our arguments yet.

    We are *absolutely* willing to bend in the face of evidence. We’re just not willing to bend *without* evidence. Show me the evidence homeopathy works; I’ll accept it if it’s good. But show you evidence that homeopathy doesn’t work and you accuse us of being “scienceologists”. Who is the closed-minded one here?

    You claim we will not bend an inch, but you haven’t really done much to convince us that we’re wrong. You also are ignoring the very real dangers of thinking a placebo works. Hint: “placebo effectiveness” actually means “no measurable effectiveness”. Placebos intentionally don’t work; any perceived benefit from them is generally an illusion, and they’re used in research because these illusions are so potent and pernicious and also universal to humanity.

  28. #28 Uglyhip
    June 30, 2011

    David Freedman: can you name one person, anywhere, who would argue that homeopathy provides zero benefit whatsoever, including placebo? If not, then you are setting fire to straw as part of the time-honored method of holding your head above the fray of the squabbling masses by appealing to a Golden Mean.

    Can you name the inch of ground we’re supposed to yield (apart from the placebo thing which we already have) so as not to be so Terribly Fundamentalist?

    “Neither camp has it right”, come on, even you don’t believe that tosh. There is a rather important difference between not having yet cured cancer, and not having yet cured anything. You know how much “bother sides” differ in results; you just hold them to different standards so that you get to say “Both Sides! Both Sides!”

  29. #29 Matthew Cline
    June 30, 2011

    @David H. Freedman:

    and this community claiming that any claims via any mechanism whatsoever for benefit to patients of alt med has been scientifically proven to be nonsense, with no one willing to bend an inch in the face of significant evidence

    If an alt-med practice has significant (and methodologically sound) evidence that it works, it ceases to be alternative medicine and becomes ordinary medicine. Unless you’re talking about significant evidence for the placebo effect, in which case current day conventional doctors have a problem with lying to their patients for their own good.

  30. #30 Vicki, Chief Assistant to the Assistant Chief
    June 30, 2011

    “There’s nothing in the middle of the road but yellow lines and dead armadillos.”

    Just because there are two positions doesn’t mean the truth must be somewhere between them. If that was how logic and reality worked, I could set up a website arguing that homeopathy was actively poisonous and a Communist plot to contaminate our precious bodily fluids. Simply by stating that position publicly, I would have created a new reality in which the “reasonable” position would be that homeopathy is actively dangerous, but the Communists have nothing to do with it.

    Would you then argue that it was unreasonable for people to claim that homeopathy is pure water and thus unlikely to hurt anyone except by distracting them from getting actual medical care? Or would you stick to your position that it is, in fact, an expensive placebo, and not going to poison its users?

  31. #31 Dangerous Bacon
    June 30, 2011

    “It sounds to me like (Freedman has) redefined scientism to avoid the criticism that you’ve unnecessarily coined a new word, I’m afraid.”

    Or to avoid criticism for the latest restatement of a tired, hackneyed and inaccurate meme beloved by wooists.

    Different word, same old bullshit.

  32. #32 Blasphemous_Kansan
    June 30, 2011

    Freedman on ‘scienceology': “When a proponent of one particular view or theory in a presumably scientific debate consistently fails to yield any ground on any points, or concede any possible truths to any aspect of the opponent’s views, I fear I’m dealing with scienceology.”

    So, following your logical flow to define ‘scienceology’, the first step to determining whether someone is a ‘scienceologist’ is to first determine if the issue at hand is a scientific one. Let’s see how this works in a practical, non-controversial, example:

    If I claim that I am close to a breakthrough in the alchemic process that would turn lead into gold, and you call my idea nonsensical, then could I call you a close-minded scienceologist, since you’re not even open to the possibility that I might be a little bit correct? Well, according to you, first we need to decide whether the issue is scientific or not. How would we do that? Well, we’d probably look at the history of the issue, the state of the consensus, and the evidence. In other words: with SCIENCE!

    Herein lies the problem: The central feature of ‘scienceology’ (according to Freedman) seems to be a blind and rigid conformity to the consensus without being open to new possibilities. Yet you rely on that very same rigidity to even define what issues ‘scienceology’ could refer to! If you didn’t, then at this point you’d have to say that my alchemy gold-making might have some grain of truth to it. In that case, I think I’d be able to argue that your eternally open-minded method of learning about the universe is objectivly awful, as it has already failed us in this medieval example.

    So you use scientific consensus and knowledge to decide what issues are scientific, then proceed to bash people over the head with that same process of consensus and label them as scienceologists?

    As circular logic goes, I think the definition of ‘scienceology’ is very impressive.

  33. #33 Jud
    June 30, 2011

    Mr. Freedman –

    Examined closely, your position does not hold water.

    I define scienceology (and I get to define it, because I made it up) as acting as if (and presumably believing that) one is applying science-like thinking when one is actually applying religion-like thinking.

    Consider the following specific issues: (1) Does thimerosal in vaccines cause autism? A belief that, e.g., thimerosal in vaccines is an agent that causes autism, now that thimerosal has been removed from most vaccines and autism rates haven’t declined, would qualify as “religion-like thinking.” Taking the evidence into account would, on the other hand, qualify as science-like (or scientific) thinking. (2) Does the MMR vaccine cause autism through measles infection of the gut and/or brain? Epidemiological studies of hundreds of thousands of children have found no link; the initial paper proposing the link has been shown to be a product of fraud; and the lab results have been discredited by a number of reviewers, as well as the person in charge of running the lab tests. Continuing to believe the MMR vaccine causes a syndrome that in turn causes autism in the face of this evidence is “religion-like thinking,” while saying the evidence has failed to demonstrate a link would be scientific thinking.

    Now add in various other anti-vaccine claims. Presumably in each of these specific cases it would not strike you as a bad thing if I took the evidence-based side. Yet the end result would be that I would “consistently fail[] to yield any ground on any points, or concede any possible truths to any aspect of the opponent’s views.”

    If I credit 10 or 50 or 100 individual propositions on the basis of good data, how does the sum of those turn into “scienceology”? If the individual conclusions are scientifically supported, a person holding all of those conclusions is thinking scientifically, not dogmatically.

    Nor, I surmise, would you object to the general notion that the efficacy of medical treatments should be evaluated based on data. So presumably someone holding that general position would not be “applying religion-like thinking.”

    Where then does “scienceology” come from?

    I think you are confuting a similarity of tone with similarity of content (or its lack):

    But I honestly have been taken largely by surprise by the scienceology that I think is rampant in this community. The two extreme camps sound almost exactly alike to me

    By itself, strong belief by both “camps” proves nothing, if belief in the one instance is based on data, and in the other instance is based on dogma. But in any case, I do not think reality accords with your stated view that there are two equivalently certain and strident camps:

    this community claiming that any claims via any mechanism whatsoever for benefit to patients of alt med has been scientifically proven to be nonsense

    I’ve seen a lot of discussion here of evidence showing lack of benefit of particular, individual types of alt med (e.g., homeopathy), non-placebo benefits of other modalities (e.g., electrical stimulation and massage/physical therapy), and in the case of Dr. Ornish, criticism that the benefits of his treatment modalities do not appear to be so great as claimed. It is the criticisms that appear to be individualized and data-based, and your response (“…this community claiming that any claims via any mechanism whatsoever…”) that appears to be non-specific and to disregard contradictory data.

  34. #34 Scott Cunningham
    June 30, 2011

    Calli Arcale

    It is clear to me that not only does Freedman not really know much about these treatments and the patients who receive them, but he’s not really very interested in learning more. He’s in good company; most of the practitioners are that way also

    It’s a common fault. Usually, strict adherents to CAM or the unerring truth of religious texts know as much about what they’re adhering to as they do about End User License Agreements. Just click OK.

    David H Freedman:

    What I mean by scienceology is in some ways the opposite of scientism. I define scienceology (and I get to define it, because I made it up) as acting as if (and presumably believing that) one is applying science-like thinking when one is actually applying religion-like thinking.

    Nice distinction without a difference, sir. That’s usually what scientism charges are. And man, you’re wagging a finger in the wrong direction.

    Obviously determining who should be labeled a scienceologist is a subjective affair, but here’s one little field test that I find helpful: When a proponent of one particular view or theory in a presumably scientific debate consistently fails to yield any ground on any points, or concede any possible truths to any aspect of the opponent’s views, I fear I’m dealing with scienceology.

    That, sir, is committing the Golden Mean fallacy. I’ve got Bingo!

  35. #35 seeker
    June 30, 2011

    re Orac: “I do love science, which is one reason why I get so agitated when I see it abused. Since I also love medicine, it agitates me even more to see both science and medicine abused”

    I respect this statement as science and medicine should be well-evidenced, and I applaud your efforts to critically look at those who deviate from scientific principles. Your sentiments are well-echoed by Michael Wilkes, a professor of medicine and vice dean of education at the University of California, Davis: “We don’t like to acknowledge the uncertainty of medicine, either to ourselves or to our patients…But patients deserve to know when their doctor’s recommendation is backed up with good evidence and when it isn’t.”

    I do, however, find it interesting that you, Orac, come from the medical specialty where “NOWHERE IN MEDICINE IS THIS MORE OF A PROBLEM THAN IN SURGERY. Even essential surgery may pose risk of infection, medical error, or a bad reaction to anesthesia. But risks are compounded because many common surgical techniques are not as effective as physicians believe or are simply performed on the wrong patients, says Guy Clifton, a neurosurgeon at the University of Texas Medical School at Houston and author at Flatlined: Resuscitating American Medicine.

    In 1989, as part of an effort to improve carotid surgery, vascular surgeons began employing a technique called stenting to prop open clogged carotid arteries with metal mesh tubes. Stenting is less invasive, but that does not necessarily mean it is safer. One study, conducted in France
    and published in 2006 in the New England Journal of Medicine, had to be stopped because stenting was killing patients. Another large study, out this year, found that 4.7 percent of endarterectomy patients had a stroke or died within four years after surgery, compared with 6.4 percent of those receiving stents. Rothwell is not optimistic that even this evidence will dampen surgeons’ enthusiasm for stents. “One issue is how these fashions arise in medicine—why do doctors accept a new technique and begin using it widely?” he says. “Innovation in medicine is not synonymous with progress.”

    YET NO COUNTRY HAS SET UP A SYSTEMATIC PROGRAM FOR EVALUATING NEW SURGERIES.

    So it’s odd that you critically attack other modalities for a lack of supporting evidence while your own profession is equally guilty of the same inconsistencies. Where is your agitation for this grand abuse? Seems the pot is most certainly calling the kettle black.

    I look forward to your response.

  36. #36 skeptic of doom
    June 30, 2011

    re Orac: “I do love science, which is one reason why I get so agitated when I see it abused. Since I also love medicine, it agitates me even more to see both science and medicine abused”

    I respect this statement as science and medicine should be well-evidenced, and I applaud your efforts to critically look at those who deviate from scientific principles. Your sentiments are well-echoed by Michael Wilkes, a professor of medicine and vice dean of education at the University of California, Davis: “We don’t like to acknowledge the uncertainty of medicine, either to ourselves or to our patients…But patients deserve to know when their doctor’s recommendation is backed up with good evidence and when it isn’t.”

    I do, however, find it interesting that you, Orac, come from the medical specialty where “NOWHERE IN MEDICINE IS THIS MORE OF A PROBLEM THAN IN SURGERY. Even essential surgery may pose risk of infection, medical error, or a bad reaction to anesthesia. But risks are compounded because many common surgical techniques are not as effective as physicians believe or are simply performed on the wrong patients, says Guy Clifton, a neurosurgeon at the University of Texas Medical School at Houston and author at Flatlined: Resuscitating American Medicine.

    In 1989, as part of an effort to improve carotid surgery, vascular surgeons began employing a technique called stenting to prop open clogged carotid arteries with metal mesh tubes. Stenting is less invasive, but that does not necessarily mean it is safer. One study, conducted in France
    and published in 2006 in the New England Journal of Medicine, had to be stopped because stenting was killing patients. Another large study, out this year, found that 4.7 percent of endarterectomy patients had a stroke or died within four years after surgery, compared with 6.4 percent of those receiving stents. Rothwell is not optimistic that even this evidence will dampen surgeons’ enthusiasm for stents. “One issue is how these fashions arise in medicine—why do doctors accept a new technique and begin using it widely?” he says. “Innovation in medicine is not synonymous with progress.”

    YET NO COUNTRY HAS SET UP A SYSTEMATIC PROGRAM FOR EVALUATING NEW SURGERIES.

    So it’s odd that you critically attack other modalities for a lack of supporting evidence while your own profession is equally guilty of the same inconsistencies. Where is your agitation for this grand abuse? Seems the pot is most certainly calling the kettle black.

    I look forward to your response.

  37. @David H. Freedman:

    “When a proponent of one particular view or theory in a presumably scientific debate consistently fails to yield any ground on any points, or concede any possible truths to any aspect of the opponent’s views, I fear I’m dealing with scienceology.”

    What if the entirety of the opponent’s position is actually false and without any scientific merit? One should only yield ground when yielding is warranted based on quality evidence and logical support. One should not yield ground just to be nice in a discussion. I need not yield any ground to a flat Earther, young Earth creationist, Moon Hoaxer, free energy proponent, or any other pseudo-scientific crank if their positions are bunk.

    If a claim cannot stand up the the crucible of science and reason, I see no reason to yield anything to anyone.

    Furthermore, by your definition, it seems you must apply your new label (of which you seem so proud) to yourself. You have a position from which you have not yielded any ground or conceded any possible truths to any aspect of the Orac’s views. Keep digging in the sand if you wish.

  38. #38 SC (Salty Current)
    June 30, 2011

    Can you dish out some insolence on Jerry Coyne’s claims about medical psychiatry?

    Yes, I’d especially like to see Orac school Irving Kirsch on the placebo effect. Oh, wait…

    Orac, as I said at WEIT, I really hope you read the works in question – critically, of course – (and perhaps also consult with Ben Goldacre) before you write anything substantive about this. Your views are influential, and an ill-considered post from you on the subject could be harmful to science-based medicine and public health. I especially hope that you keep in mind the problems of anecdote and “personal clinical experience” in this area.

    Hint: “placebo effectiveness” actually means “no measurable effectiveness”.

    No, that’s wrong.

  39. #39 won4all
    June 30, 2011

    not much of a “science” blog when you won’t print a comment constructive criticism that challenges the author to stand up to his own convictions. what a farce.

  40. #40 won4all
    June 30, 2011

    lol. impress me and post this:

    re Orac: “I do love science, which is one reason why I get so agitated when I see it abused. Since I also love medicine, it agitates me even more to see both science and medicine abused”

    I respect this statement as science and medicine should be well-evidenced, and I applaud your efforts to critically look at those who deviate from scientific principles. Your sentiments are well-echoed by Michael Wilkes, a professor of medicine and vice dean of education at the University of California, Davis: “We don’t like to acknowledge the uncertainty of medicine, either to ourselves or to our patients…But patients deserve to know when their doctor’s recommendation is backed up with good evidence and when it isn’t.”

    I do, however, find it interesting that you, Orac, come from the medical specialty where “NOWHERE IN MEDICINE IS THIS MORE OF A PROBLEM THAN IN SURGERY. Even essential surgery may pose risk of infection, medical error, or a bad reaction to anesthesia. But risks are compounded because many common surgical techniques are not as effective as physicians believe or are simply performed on the wrong patients, says Guy Clifton, a neurosurgeon at the University of Texas Medical School at Houston and author at Flatlined: Resuscitating American Medicine.

    In 1989, as part of an effort to improve carotid surgery, vascular surgeons began employing a technique called stenting to prop open clogged carotid arteries with metal mesh tubes. Stenting is less invasive, but that does not necessarily mean it is safer. One study, conducted in France
    and published in 2006 in the New England Journal of Medicine, had to be stopped because stenting was killing patients. Another large study, out this year, found that 4.7 percent of endarterectomy patients had a stroke or died within four years after surgery, compared with 6.4 percent of those receiving stents. Rothwell is not optimistic that even this evidence will dampen surgeons’ enthusiasm for stents. “One issue is how these fashions arise in medicine—why do doctors accept a new technique and begin using it widely?” he says. “Innovation in medicine is not synonymous with progress.”

    YET NO COUNTRY HAS SET UP A SYSTEMATIC PROGRAM FOR EVALUATING NEW SURGERIES.

    So it’s odd that you critically attack other modalities for a lack of supporting evidence while your own profession is equally guilty of the same inconsistencies. Where is your agitation for this grand abuse? Seems the pot is most certainly calling the kettle black.

    I look forward to your response.

  41. #41 Matthew Cline
    June 30, 2011

    @won4all:

    Comments get automatically held up for moderation if they trigger the spam filter. Among other things, including more than two links triggers the filter. Wait for Orac to approve your comment.

  42. #42 won4all
    June 30, 2011

    thanks…will do

  43. #43 sceptinurse
    June 30, 2011

    —So why are we arguing over whether or not acupuncture is a placebo? We have three licensed acupuncturists and two physician acupuncturists at The Scripps Center for Integrative Medicine. I can cite patient after patient who has received benefit from our acupuncture program. And in regard to Dr. Salzberg’s post, I have never seen a punctured lung or infection as a result of an acupuncture treatment. While I am sure complications can occur, they are certainly much less common than the hospital-acquired infections I saw as an interventional cardiologist.—

    I’d like to add my anecdotes to this quote from the doctor who thinks acupuncture is better and safer than real medicine.

    I tried it for my asthma. It did help some. At the time I was doing this my asthma had a highly emotional component to it. (I worked a lot of hours and took a lot of call and was going through a divorce at the time). What the acupuncture sessions gave me was a couple of hours a week to relax and think about things. In retrospect someone could have just locked me in a comfortable room with no distractions for a couple of hours a week and I’m sure the effect would have been the same.

    During this treatment phase I sustained a hematoma in between my first and second metacarpals. In addition to being extremely painful this rendered my hand almost useless for a few days. Not a good thing for a circulating nurse.

    While I was doing this I had an exacerbation of my low back pain so it was added to the mix. I found that the treatments for that usually did help immediately. And lasted until I got home. The only treatment I ever had for pain that didn’t come back was for a headache (surprise, surprise).

    So over all I have to conclude that trying acupuncture was an expensive waste of my time. Not the conclusion the “good” doctor quoted above would want me to reach I’m sure.

  44. #44 SC (Salty Current)
    June 30, 2011

    David Freedman:

    I agree! Alt med is plagued with scienceology. That’s why I stipulated high up in my article that the treatments don’t work better than placebo–to short-circuit the whole tiresome argument over the direct physical effectiveness (as opposed to placebo effectiveness, which no one disputes) of these treatments. But I honestly have been taken largely by surprise by the scienceology that I think is rampant in this community. The two extreme camps sound almost exactly alike to me–the most aggressive alt-med proponents claiming that homeopathic (for example) remedies have been scientifically proven to work exactly as advertised, and this community claiming that any claims via any mechanism whatsoever for benefit to patients of alt med has been scientifically proven to be nonsense, with no one willing to bend an inch in the face of significant evidence and general mainstream-medical-science-practitioner agreement that neither camp has it right. Well, people know for sure what they know for sure, there’s no making a dent in it!

    Do I have this right?: Is your argument that CAM – both the “treatments” themselves and the alleged considerateness of practitioners – works solely via the placebo effect, and everyone should accept and even celebrate this? Despite the condescension involved, the real potential dangers of many CAM treatments, the huge amounts of money going to CAM practitioners and the hawkers of CAM products (who do not represent their products as placebos), the false hope instilled in people, the drawing people away from treatments that may be both cheaper and effective beyond placebo, the distracting people from fighting for a healthcare system that looks at these problems in terms of public health and allows physicians to care for patients as fully as they can, and the subversion of a basic understanding of and respect for science at a time when that understanding is most desperately needed? Is that your position?

  45. #45 Calli Arcale
    June 30, 2011

    SC — you’re quoting me, not Orac (just to clarify so people know who you’re correcting).

    Yes, I’m greatly oversimplifying, and you’re right, it was a mistake. I was trying to counter what Freedman was implying about the placebo effect; he seems (and he is free to correct me if I’m wrong) to believe that the placebo effect is an actual, single effect that is being triggered by homeopathy and other alt med modalities when this is not at all what the placebo effect is. My intention (very badly worded) was to say that when comparing a study drug against a placebo, if the study drug has no effect you will find no measurable (at least to a significant degree) difference between it and the placebo. At which point you know the study drug is worthless for this indication.

    So whether or not the placebo effect does something beneficial isn’t all that important; if a treatment fails to surpass the placebos, it’s a waste of time and money.

  46. “Seems the pot is most certainly calling the kettle black”

    Even if your lame tu quque fallacy was valid, a pot calling a kettle black does not make the kettle white.

  47. #47 won4all
    June 30, 2011

    calli

    “if a treatment fails to surpass the placebos, it’s a waste of time and money.”

    what do you make of treatments that aren’t even put to the test, i.e., no money is spent on the testing of its efficacy and it is just accepted as efficacious and thus widely used, like some alt meds and, as mentioned in post 40, surgery?

  48. #48 won4all
    June 30, 2011

    blog.cordialdeconstruction.com

    please explain how this is not hypocritical (that Orac, who demands scientific evidence of other therapies to validate their efficacy, himself comes from a medical profession that does not provide its own scientific evidence)?

    his profession’s practice doesn’t even stand up to his own criticism.

  49. won4all,

    Again, even if we accepted your position that surgery is guilty of the same inconsistencies as CAM, to the same extent and degree as CAM (which I certainly don’t), is it then your position that we should:

    A. Ignore science all together and give CAM free reign,
    B. Ignore science and and give CAM free reign until science is applied universally, or
    C. Something else?

  50. #50 llilady
    June 30, 2011

    @ won4all: I believe you are referring to the second study conducted/published in the NEJM on July 1, 2010 that describes the 4 year survival rate of carotid artery stenting -vs- endarterectomy with 4 year survival rates of 6.4 % -vs- 4.7 % respectively. It is available as a Pub Med citation:

    PMID 20505173 Stenting versus endarterectomy for treatment of carotid-artery stenosis.

    Here is the “conclussion” of that citation:

    CONCLUSIONS:

    Among patients with symptomatic or asymptomatic carotid stenosis, the risk of the composite primary outcome of stroke, myocardial infarction, or death did not differ significantly in the group undergoing carotid-artery stenting and the group undergoing carotid endarterectomy. During the periprocedural period, there was a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy. (ClinicalTrials.gov number, NCT00004732.)

    2010 Massachusetts Medical Society

    I don’t think we still have answers about the risks-vs-benefit of stenting -vs- endarterectormy…unless we could define any other individual characteristics of the patients in the study that would identify which individual is at higher risk for stroke as opposed to myocardial infarction.

  51. #51 Calli Arcale
    June 30, 2011

    what do you make of treatments that aren’t even put to the test, i.e., no money is spent on the testing of its efficacy and it is just accepted as efficacious and thus widely used, like some alt meds and, as mentioned in post 40, surgery?

    I’m not crazy about them. I understand that sometimes stuff has to be done in the absence of good data; sometimes you have to take a chance. That’s especially true in surgery, where decisions have to be made very quickly, but it also happens in pharmaceuticals, especially off-label use of pharmaceuticals. Somebody does have to be the first, after all, or it won’t get anywhere. But any use of a treatment pending investigation has to be disclosed as such, so the patient understands the state of the evidence, and it should eventually get studied properly. If it is eventually studied and proven worthless, then it should be abandoned.

    This abandonment does not always happen as quickly as I’d like, but at least there is a vehicle for such correction.

  52. #52 won4all
    June 30, 2011

    blog.cordialdeconstruction.com

    It is not “my position” that surgery is guilty of the same inconsistencies; this is a known fact.

    Or were you unaware that the U.S. Food and Drug Administration (FDA) regulates drugs, devices, and many tests, but it does not control how doctors use them and has no control at all over surgeries. Lack of strong oversight means doctors often have limited information about side effects, even from products and procedures used for years. One surgeon who complained says, “Device makers could sell us a piece of curtain and call it surgical mesh and
    we wouldn’t know the difference.”

    What I suggest is that you understand a simple and obligatory requirement about science…objectivity. If one is not able to be objective, then they fail to be scientific. If one points their fingers one way yet is also guilty of the same criticism, this is called bias, which undermines the very meaning of being scientific. And one who is biased cannot then be seen as credible.

    So what I suggest is that Orac build up his credibility by learning to be more objective (rather than remain unscientific) by also looking at his own profession, that is if his true purpose is the safety of all patients.

    Or he can disregard the studies pointed out (e.g., a greater number of patients dying (6.8%) after receiving stents than endarterectomy patients (4.7%), as outlined in the New England Journal of Medicine), as you seem to be doing by ignoring this documented study that I provided and you have merely relegated to “my position.”

  53. #53 SC (Salty Current)
    June 30, 2011

    SC — you’re quoting me, not Orac (just to clarify so people know who you’re correcting).

    Yes. I often neglect to specify or divide the sections of my comments as I should. Apologies.

    Yes, I’m greatly oversimplifying, and you’re right, it was a mistake. I was trying to counter what Freedman was implying about the placebo effect; he seems (and he is free to correct me if I’m wrong) to believe that the placebo effect is an actual, single effect that is being triggered by homeopathy and other alt med modalities when this is not at all what the placebo effect is.

    Hmm.

    My intention (very badly worded) was to say that when comparing a study drug against a placebo, if the study drug has no effect you will find no measurable (at least to a significant degree) difference between it and the placebo.

    The placebo effect is the measurable difference between treatment with a placebo and no treatment. The difference between the measured effect of the drug and that of the placebo is the drug effect. (It’s a bit complicated because that rests on the assumption that the effects are additive which isn’t always necessarily the case, but that’s basically it.) So you can have a situation in which you find no significant measurable difference between the effect of the drug being evaluated and the placebo, but people taking both show significant measurable improvement.

    You might find Kirsch’s book of interest as well. *runs*

  54. #54 rob
    June 30, 2011

    scienceology is not a good word. let’s break it up into “science” and “ology”

    science means science.

    ology is a suffix referring to science or other branch of knowledge.

    so this word means science science? study of science? kinda redundant, eh?

    since the word is supposed to mean ” acting as if (and presumably believing that) one is applying science-like thinking when one is actually applying religion-like thinking.”

    i propose keeping the -ology, but tacking it on after “dumb”

    so…dumbology.

    wait! inaneology. no no no. here it is:

    people-who-don’t-listen-to-me-and-think-cam-is-bullshit-ology.

  55. #55 jaranath
    June 30, 2011

    I sure hope you just ignore most of your critics, Mr. Freedman. Because otherwise, you’re a baldfaced liar. Over the course of this farce, several of us have acknowledged that there are placebo effects at work in alt-med, as well as the possibility that genuinel medicine may fall short in incorporating and practicing those aspects of alt-med that generate placebo effects, especially improved doctor-patient interaction. That we have also asked you to support the claim that alt-med is indeed superior in that regard does not mean we dismiss the possibility, or think that real medicine couldn’t benefit from doctors with fewer patients, more time, and better bedside manners.

    You have acknowledged none of this. Likewise, you have not acknowledged that your critics are generally well aware that many alt-med practitioners believe in what they’re selling, instead choosing to paint us as believing it’s evil. But while fraud exists, we know damn well a lot of these people are True Believers. It’s long past time you start listening, sir.

  56. #56 Denice Walter
    June 30, 2011

    I should speak now or forever hold my peace:

    Perhaps our critics just don’t *get* probablity, research design, and statistical analysis and why we _like_ it so much? And dream about it!

    I’m off on a weekend trip or else I’d rhapsodise for you.

  57. #57 Mutant Dragon
    June 30, 2011

    I would be astonished by the Atlantic’s shoddy journalism, if only all science and health reporting weren’t so terrible nowadays. The whole thing is just a massive apologia for pseudoscience disguised as the usual “telling both sides of the story” nonsense.

  58. #58 Michael Johnson
    June 30, 2011

    I think the commenters who’ve said that we on the evidence based side already recognize the “value” of elaborate placebos are right, and that Freedman has set up a straw man.

    But I think he does so because he is mistaken about the nature of the debate. He thinks that alt-med should be accepted to some extent because of this “value” and that closed-minded scienceologists won’t move to this middle of the road position.

    But I take it that the Oracophiles don’t want to occupy the middle of the road– not because they insufficiently appraise the “value” of elaborate placebos, but because they find doing so morally abhorrent. In particular:

    1. It is wrong to lie to patients and misrepresent how medicine works and the extent to which the treatments being offered are effective. CAM practitioners do this.

    2. It is wrong to take more of a patient’s money than it costs to provide a treatment with the same effect. We understand the basic principles of how talking with patients and providing a comforting atmosphere works (which is the mechanism by which alt med works, when it does). We could provide these things to patients at a cost lower than alt med treatments, and this is what Orac has come out in support of (more funding for doctors to do this).

    3. It is wrong to subject patients to unnecessary treatments when those treatments carry a real risk of harm. As many in the comments have pointed out, acupuncture, aryuveda, chiropracty, etc. do present a real risk of harming patients.

    If you asked me why I won’t budge and move to the middle of the road, it’s not scienceology, it’s morality.

  59. #59 Uglyhip
    June 30, 2011

    Michael Johnson: excellent points! Now I wonder if, with Freedman, there really is any disagreement over non-moral facts — rather than, as is more likely, an ethical debate going on here.

  60. #60 Mandos
    July 1, 2011

    “3. He may be fooling himself with the notion that taking a middle-ground position makes one reasonable and likely to be right.”

    Oy. This is a huge problem with Big Journalism and not just on the matter of alt-med. Journalists seem to take it as religion that both sides of the story are partly true, and the effects are pernicious.

  61. #61 Vasha
    July 1, 2011

    Michael Johnson: Thank you for that!

  62. #62 Chris
    July 1, 2011

    Matthew Cline:

    Comments get automatically held up for moderation if they trigger the spam filter.

    won4all (and seeker) seem to be spamming a bit today. His question has been answered, and we don’t have to engage in his off topic diversions anymore.

  63. #63 Chris
    July 1, 2011

    Matthew Cline:

    Comments get automatically held up for moderation if they trigger the spam filter.

    I saw the exact same comment posted by seeker/skeptic of doom/won4all posted on two other blogs. It looks like there was a reason for it to be held up. His question has been answered on one of the blogs.

  64. #64 Jarred C
    July 1, 2011

    Rob said,

    scienceology is not a good word. let’s break it up into “science” and “ology”

    science means science.

    ology is a suffix referring to science or other branch of knowledge.

    so this word means science science? study of science? kinda redundant, eh?

    since the word is supposed to mean ” acting as if (and presumably believing that) one is applying science-like thinking when one is actually applying religion-like thinking.”

    i propose keeping the -ology, but tacking it on after “dumb”

    so…dumbology.

    wait! inaneology. no no no. here it is:

    people-who-don’t-listen-to-me-and-think-cam-is-bullshit-ology.

    Thank you, rob! Although, secretly, I was hoping no one would have mentioned this, because I wanted to. :)

    As for the definition that Mr. Freedman imposed upon the improper junction of science and -ology, it seems to be more appropriately applied to an -ism suffix. The -ism suffix is usually used in terms of religion (Catholicism, Hinduism, Buddhism, etc..), so the connection of science and -ism would make much more sense, linguistically. And what do you know! The term ‘scientism’ addresses that concept already!

    I do have to nitpick one thing, rob. I can’t stand it when people create new words mixing english and greek/latin. Mixology, shakeology, shoeology, etc.. It’s just painful to hear. If you’re going to use a greek suffix, at least use the greek (or latin) version of the stem you want to use!

    I would figure that Mr. Freedman, as a writer, would know this. I mean, seriously here, when you look at a word, you should be able to figure out what it means by the affixes involved.

  65. #65 Jarred C
    July 1, 2011

    Blockquote fail. Sorry, folks.

  66. #66 Wrysmile
    July 1, 2011

    Mr Freedman is the Mooney of the alt med/cam world. An alt med/cam accommodationist, He seems to think there is a middle ground where there is none. Sometimes an idea is just plain wrong.

  67. #67 Jud
    July 1, 2011

    won4all writes @47:

    what do you make of treatments that aren’t even put to the test, i.e., no money is spent on the testing of its efficacy

    won4all writes @52:

    Or he can disregard the studies pointed out (e.g., a greater number of patients dying (6.8%) after receiving stents than endarterectomy patients (4.7%), as outlined in the New England Journal of Medicine)

    When you are finished arguing with yourself regarding whether the efficacy of surgical procedures is studied or not, please let us know which one of yourselves won.

  68. #68 rob
    July 1, 2011

    Jarred C:

    if you are having problems with block quotes, i have a book you can borrow: blockquoteology and modern society.

    ;)

  69. #69 Calli Arcale
    July 1, 2011

    Another useful point for won4all — Orac does from time to time discuss problems within the surgical community. To suggest that he is arrogantly ignoring these matters merely because won4all did not see that addressed in this particular post is a little silly.

  70. #70 Chris
    July 1, 2011

    Calli, I googled the sentence he wrote in all caps, and noticed it was from an Atlantic article by a pair of authors that Orac has discussed before. So to be honest won4all could channeling other credulous Atlantic writers (though he posted his rant on an article elsewhere that were pretty much off topic).

  71. #71 won4all
    July 1, 2011

    Here’s my response to Orac. Chris, does the source of my capitalized words in any way change the reality or fact that new surgical procedures have no evaluative systematic programs in any country?

    Orac,

    Thanks for your reply. It’s commendable that breast surgery is purportedly the most scientifically grounded surgical speciality and that you’ve written critically about vertebroplasty in the name of good science and medicine.

    As you state that you “do love science, which is one reason why I get so agitated when I see it abused,” it’s puzzling that you’ve only tackled a specific surgical speciality (vertebroplasty) rather than surgery as a whole when the FDA regulates drugs, devices, and many tests, but does not control how doctors use them and the FDA HAS NO CONTROL OVER SURGERIES.

    Compared to the much smaller percentage of breast-cancer-surgery and vertebroplasty patients, I would think that your scientific and medical indignation and keen insight would be more perceptive to and more highly motivated to expose the grosser medical problem of surgery as a whole. As a man of science and medicine, which you claim you are, shouldn’t it be your responsibility then to write about the state of surgery whereby no country has set up a systematic program for evaluating new surgeries?

    Lack of strong oversight means doctors often have limited information about side effects, even from products and procedures used for years and especially the efficacy of many surgical procedures. One surgeon who complained says, “Device makers could sell us a piece of curtain and call it surgical mesh and we wouldn’t know the difference.”

    The fact that the FDA has no control over surgeries and that no country has set up a systematic program for evaluating surgeries = very poor regulation and lack of science-based evidence, which is, if I may borrow from your lexicon, “pure crank” and “woo” of the grandest order.

    As a person who “already [does] hold all medicine up to the same standard,” your criticisms seem oddly selective, i.e., you freely criticize all CAM as a whole, yet discuss but a specialty or two from the whole of surgery (which, again, lacks stringent regulation and clinical evidence). And we all know that in science, a selective viewpoint is nothing but bias…the antithesis of objectivity, a key requirement of science. As an objective man of science and true crusader of what is right for patients, you are required to critically analyze surgery as a whole, and not just a specialty or two…

    Cheers.

  72. #72 elburto
    July 3, 2011

    seeker/skeptic/won4all/dicksplash – by ‘no country’ do you mean “I’m a stupid American who thinks that because something doesn’t exist here, it can’t exist anywhere”? I very much think you do. NICE?

    re:skepticalob discussion – Amy Tuteur is not a doctor of any sort. Her posts are lifted wholesale from social networking sites, and then spammed the length and breadth of the internet, to earn money via embedded ads. The rhogam discussion never happened. I’ve seen it reposted over and over again this weekend, and it’s doing my head in. She’s lying, don’t reward her with page hits.

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