White Coat Underground

Before you trust that blog…

Doug Bremner has a blog. That blog sucks.

Bremner is an apparently well-regarded psychiatrist, and takes a refreshing look at the influence of industry not just on pharmaceuticals but on the conduct of science itself. His outspoken views have led to attempts to squelch his academic freedoms. But his sometimes-heroic record does not excuse dangerous idiocy.

I can understand how wading into the shit pool that is conflict of interest can leave one cynical. But cynicism and suspicion turned up to “11” is no longer bravery—it’s crankery. It’s not his snarkiness that burns—it’s his inability to separate his biases from the facts.

It’s not like the pharmaceutical industry doesn’t deserve to be taken to the wood shed. Examples of unethical and downright immoral practices abound, such as ghost-writing, fake journals, and a host of other sins. But the industry has also helped develop a most remarkable pharmacopeia which saves and improves countless lives. There is good, and there is bad. And telling the two apart, well, that makes all the difference.

He tends to go for headlines that hit hard, but miss the point entirely. Examples:

  • Angioplasty Found to be Useless Waste of Money: he cites a journal article which he says concluded that “not useful for patients with stable coronary artery disease (CAD). ” His title would be accurate if angioplasty were used only in stable CAD—it is not.
  • Should I Take Aspirin or Put a Gun To My Head?: here, he sort of gets the difference between primary and secondary prevention, but not really. He also likes to admit that the data contradict his conclusion but he’s nice enough to say, “screw the data”:

    Although technically the risk of stomach bleeding is outweighed by the heart benefits of aspirin (which can only be shown when large numbers of patients are studied), in terms of what that means to you the differences are clinically meaningless.

  • This Just In: Breast Cancer Screening Essentially Useless: yes, Doug, breast cancer screening doesn’t benefit everyone equally. For example, the prevalence of breast cancers in men is low enough that recommending it for you would be stupid—like your article.


This type of consistent inconsistency is why a headline like this is hard to take seriously: Flu shots are [still] for idiots. It’s always good to re-examine the evidence behind our practices. Influenza vaccination uses tremendous resources, and it’s important to know what benefit, if any, we get from this expenditure. But Doug hates evidence that contradicts his pre-formed conclusions, so conveniently ignores it.

First, though, his “facts” are wrong. For example:

The problem is that there are many strains of flu and the vaccine targets only one, and you need the shots every year cuz the viruses keep changing.

No. Each year’s flu vaccine is a mixture of various strains that are circulating or that are likely to become the next season’s prevalent strains. I’m not sure why he sees this as a weakness. It is a weakness. If flu were more like pertussis, for example, we would only need one vaccine with occasional boosters. Flu does not comply with my wishes, and that’s sad, but that’s the way it is.

Moving on to graver sins of ill reasoning:

And that oft quoted figure of 30,000 deaths per year? Half of those cases of the “flu” are actually flu-related illness that is not actually caused by an influenza virus (and not prevented by flu shots). And most of the rest are in the elderly who often have impaired immunity so the flu shot wouldn’t work for them anyway.

The figures on flu mortality are derived from a complex model that is not without flaws. We need to estimate because we don’t test everyone. If anything, though, they underestimate flu mortality. As for the elderly having impaired immunity leading to the shot “not working”—well, that’s poppycock. This begs the question quite ferociously. His brief statement has several unfounded assertions: all elderly who get the flu have impaired immune systems; these same people would not derive sufficient immunity from the vaccine; and that half of the 30K are in this group. This many assertions in one sentence makes my head spin, but not in a good way. Whether and how much flu vaccines benefit the elderly is a difficult question, but there is significant data that the elderly benefit from these vaccines.

This of course ignored the fact that for swine flu, it it the young, not the elderly who are the primary target group for immunization. You see, all flus are not created equal. Every season is different, and broad, unsupported conclusions such as Bremner’s are usually unwise.

But back to the cherry picking: he relies strongly on a single study from the British Medical Journal by Tom Jefferson. He didn’t bother giving the actual citation, which is good for him. If he had, the reader would see that the “study” is actually an editorial, and that subsequent letters effectively eviscerated the argument. He of course does not bother to mention data that do not support his conclusions.

The reason Bremner’s blog sucks is that he’s essentially a one-trick pony. Every article is about a vast conspiracy. Without what Orac calls the “the Pharma Shill Gambit”, he’s got nothing. And given the quality of his pieces, perhaps “nothing” is what he should be doing more of.

Comments

  1. #1 The Blind Watchmaker
    September 7, 2009

    “Half of those cases of the “flu” are actually flu-related illness that is not actually caused by an influenza virus (and not prevented by flu shots).”

    If they are flu-related, then these illness are affected by getting the flu. Influenza didn’t cause the patient’s COPD or cardiomyopathy, but the illness exacerbates those conditions. This leads to hospitalizations and deaths. That is what is meant by “flu-related”.

    Elderly people do benefit from the flu vaccine as PalMD pointed out with the link to the 2007 New England Journal article. Just because they do not exhibit immunoconversions as robustly as younger folks doesn’t mean we do not vaccinate. Their responses are positive numbers. The response to not vaccinating would be zero. The flu vaccine in the elderly saves lives.

    http://www.cdc.gov/flu/about/qa/vaccineeffect.htm

  2. #2 catgirl
    September 8, 2009

    And most of the rest are in the elderly who often have impaired immunity so the flu shot wouldn’t work for them anyway.

    Even if this statement were true, the flu shot can still protect elderly people with impaired immunity simply because immunizing a lot of young and healthy people means the chances are lower that elderly people will even be exposed to the flu.

  3. #4 Orac
    September 13, 2009

    Pretty lame response, Dr. B.

    Try this one:

    http://www.sciencebasedmedicine.org/?p=1504

  4. #5 Marilyn Mann
    September 13, 2009

    For any of your readers who haven’t seen it, I’d just like to reference the recent meta-analysis of aspirin for the primary and secondary prevention of vascular disease by the Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials, The Lancet, Volume 373, Issue 9678, Pages 1849-1860, 30 May 2009.
    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60503-1/abstract
    The results for primary prevention were as follows: “aspirin allocation yielded a 12% proportional reduction in serious vascular events (0·51% aspirin vs 0·57% control per year, p=0·0001), due mainly to a reduction of about a fifth in non-fatal myocardial infarction (0·18% vs 0·23% per year, p<0·0001). The net effect on stroke was not significant (0·20% vs 0·21% per year, p=0·4: haemorrhagic stroke 0·04% vs 0·03%, p=0·05; other stroke 0·16% vs 0·18% per year, p=0·08). Vascular mortality did not differ significantly (0·19% vs 0·19% per year, p=0·7). Aspirin allocation increased major gastrointestinal and extracranial bleeds (0·10% vs 0·07% per year, p<0·0001), and the main risk factors for coronary disease were also risk factors for bleeding."
    The researchers concluded that "[i]n primary prevention without previous disease, aspirin is of uncertain net value as the reduction in occlusive events needs to be weighed against any increase in major bleeds. Further trials are in progress."
    Of course, one needs to read the whole article to get all the nuances, but these results do not preclude a net benefit for some subgroups. Notably, there were very few participants in the trials whose 10-year risk of cardiovascular disease exceeded 10 percent. It is quite possible that this group might have a net benefit.
    You may also be interested in the comments of Harlan Krumholz and Sanjay Kaul on Cardiobrief blog:
    http://cardiobrief.org/2009/05/28/antithrombotic-trialists-collaboration-questions-value-of-aspirin-in-primary-prevention/
    Would be interested to hear your (or anyone else’s) thoughts.
    Marilyn

  5. #6 PalMD
    September 13, 2009

    Once again, I must remind people that context is important. Primary and secondary prevention are not the same thing.

  6. #7 Marilyn Mann
    September 13, 2009

    In case I wasn’t clear, the meta-analysis showed a clear net benefit for secondary prevention.

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