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Anti-vaccination—old religion writ new

Posted in Denialism by Skepdude on August 25, 2008

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I’m rather angry.

Strike that.

I’m furious. Indescribably outraged. Disgusted.

The rise of the antivaccination cults is finally affecting public health. If you want details, go and read Orac, or Steve Novella, or some of my other writing. I’m too angry to deal with details today.

Infectious diseases have stalked us across the millennia. Centuries of advances, from sewerage to inoculation to vaccination have saved billions of people from death and disability due to infectious agents. Having a child used to mean joy tempered with fear—fear that one of the “men of death” would come for your child, leaving them scarred, paralyzed, deaf, mentally disabled, or dead.

We’ve been largely liberated from these fears. We are now free to fear obesity. We are free to worry about good schools, the environment, poverty. Infectious diseases aren’t the scourge they once were. Who would wish it otherwise?

There is a cult of infectious disease supporters out there, and they are winning. Before the days of vaccination, we could let ourselves believe that childhood diseases were acts of God, to be accepted as part of a normal life. Perhaps they were even deserved. Disease and death became integral to religious beliefs about sin and its wages.

The language has changed, but the message is the same. Infectious disease prevention is to be feared. It is against the natural order of things. Instead of “vaccines are against God’s will”, it’s now “vaccines are against Nature’s will.” They’re “unnatural”, not “green”. In the old vernacular, interfering with God’s will could lead to “bad things”, like flood, famine, or other divine punishment. In the new language, it leads to “autism”.

It’s the same old song. Anti-vaccination is simply a cult, with cult beliefs that stretch back thousands of years and are tied to a fear of interfering with the “natural order of things”.

If it were just a matter of these cultists endangering their own health it would be a moderate outrage. But their cult of infectious disease promotion is spreading disease. And their leaders are dangerous. In fact, they are more dangerous than a madman with a gun.

The health care community needs to speak up, but more importantly, politicians, preachers, and other leaders need to call these folks out, and show them for what they are…a bizarre, fringe religion who’s goal is the spread of infectious disease. The voices of the cultists must be drowned out by the voices of the rational. Perhaps then we can reverse the damage they have done to public health.

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Another Open Letter to Jenny McCarthy

Posted in Denialism by Skepdude on August 25, 2008

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Dear Jenny,

Thank you! Thankyouthankyou thank YOU!

You see, my medical education had a few gaps. I was unfortunate enough to do my training during the last couple of decades, which means I never saw measles, pertussis, polio, and many other vaccine-preventable diseases.

Well, last year, I saw three cases of pertussis! Sweet! And it looks like, if I play my cards right, I may get to see some measles.

It’s not that I don’t know anything about measles. I mean, I’ve read Hippocrates, Rhazes, Osler, and all the other ancients. But to see the real thing, to experience the real fear, well, you just can’t buy that kind of education. I’ve never been able to experience the fear that my little girl–who loves to swim— might bring polio home from the lake. How am I supposed to relate to my older patients if I don’t know that fear?

If I were in charge of awards for medical education, I’d give you one. But, alas, I’m not. I guess we’ll have to find some other way to honor all your hard work, education, and expertise. I mean, my four years of undergrad, 4 years of medical school, and 3 years of residency can’t hold a candle to your experience as a Mommy Warrior. I wish we could just bottle that. Or perhaps isolate it in northern Idaho.

Anyway, if you’re on google doing research for your next cult, I have a few suggestions. First, try to find one with UFOs. UFOs are kinda cool. Second, find one that makes you cut off all your ties to the outside world. As much as I’d miss the educational opportunities of your public appearances, I’ll find a way to make up for it.

So thanks, and good luck! Keep up the personal growth! Move on to the next issue!

Please?

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The latest scummy tactic of altie med – blaming medicine for celebrity deaths.

Posted in Altie Meds, Denialism by Skepdude on August 22, 2008

A fellow medical student once asked me why I thought people become hostile to science-based medicine. Certainly our own failures contribute. When we have no treatments for a disease, or if the treatments themselves may also incur significant morbidity, it is understandable that patients will become disillusioned with what doctors have to offer.

However there is another cause for this hostility towards medicine, and it isn’t the occasional crank scibling with an axe to grind against MDs. It’s the constant anti-science propaganda being spouted out by the hawkers of alternative medicine.

Orac and others have despaired over the infiltration of woo into mainstream medicine under a banner of tolerance and the noble goal of avoiding confrontation with patients over deeply-held beliefs. However this has proved more and more a tactical error as we’ve seen that CAM and altie medicine do not seek detente but is at war with legitimate medicine and science itself. Besides the fact that there is no good reason to water down medical school with unproven nonsense and the latest placebo fad being sold by crooks, alternative medicine should not be taught because doing so is not just a failing to meet the barbarians at the gate, but is actively inviting them in to destroy everything we’ve worked for.

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Doctors aren’t preachers (or at least they shouldn’t be)

Posted in Denialism, Medicine by Skepdude on August 21, 2008

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I’ve written a number of times about how a physician must be careful not impose his or her personal beliefs on patients.

Another interesting case has hit the news. The decision of the California Supreme Court hinged on interpretation of state non-discrimination law. I’m not a lawyer, but I do know a bit about medicine and medical ethics. Regardless of law, this doctor’s behavior was wrong. The details are a little sketchy, but an unmarried lesbian woman was denied fertility treatments by a California doctor because the treatment conflicted with the doctor’s faith.

Conflicted with the doctor’s faith. There’s the rub.

This is a particularly perverse form of prostelitizing. It doesn’t involve having coffee with an acquaintance and teaching them the Word. It involves a vulnerable individual, who comes to a qualified professional for help, and is turned away because of “improper” living and thinking. In this case, it is disputed whether the patient was denied care because of being gay or because of being unmarried. It doesn’t really matter. Either reason for discrimination is wrong. What matters is that the doctor felt that treating the patient would violate her own religious beliefs.

The measure of whether a treatment is appropriate is whether it conforms to standard of care, is safe, effective, and ethical (non-coercive, etc.). If a patient presents for infertility treatment, and is medically qualified, she should receive the treatment (assuming she doesn’t breed babies for snack food). The American Society for Reproductive Medicine recognizes this in several position statements. One specifically addresses unmarried and homosexual patients:

–Unmarried persons and gays and lesbians have interests in having and rearing children.
— There is no persuasive evidence that children raised by single parents or by gays and lesbians are harmed or disadvantaged by that fact alone.
–Programs should treat all requests for assisted reproduction equally without regard to marital status or sexual orientation.

When you decide to become a doctor, you immerse yourself to the neck in ethical problems for the rest of your career. Patients make bad decisions. Other doctors make bad decisions. Ethically grey conundrums pop up on a daily basis. Standards set by professional organizations help to sort some of these out, but not always. The “most wrong” decision in an ethical debate is the cop-out. For a physician to deny a patient care based on their own beliefs is a cop-out, and is a coercive use of their paternalistic powers. This decision doesn’t just deny them your personal services. It may cause permanent psychological harm to the patient. And that’s not what doctoring is all about.

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I am embarrassed

Posted in Denialism, Woo by Skepdude on August 21, 2008

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by the San Francisco Chronicle for giving a lot of uncritical coverage to a pet psychic in “Marla Steele makes pet talk a two-way street.” This “psychic” discusses Reiki (and the ability to do it from a distance–“energy broadcasting”), among other thing. And here’s the reporter’s hardball question:

What do you say to skeptics? I completely appreciate people’s skepticism. I first heard about animal communication from a coworker at Nordstrom’s who was paying $100 to talk to a pet psychic in Oregon about her German Shepherd. I always listened politely to her stories, but secretly thought she must just have money to burn, or be crazy, or both. Now we laugh because I not only became a pet psychic, I also appear on radio and television talk shows all over the country.

Pathetic!

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How we know what we know

Posted in Denialism, Medicine by Skepdude on August 19, 2008

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Over the last few decades, the nature of medical knowledge has changed significantly. Before the revolution in evidence-based medicine, clinical medicine was practiced as more of an art (in the “artisan” sense). Individuals were treated empirically with a strong knowledge of medical biology, and the guidance of “The Giants”, or particularly skilled and respected practitioners. While the opinions of skilled practitioners is still valued, EBM adds a new value—one of “show me the evidence”.

Evidence-based medicine refers to the entire practice of gathering and applying medical knowledge. This includes evaluating diagnostic tests (e.g. how well does an CT scan diagnose pulmonary embolism?) and evaluating treatments (e.g. which anticoagulant is most effective, which one is safer, how long should you treat, etc.) There will always be some questions that are untestable, and some for which no testing is needed, and practices for which evidence is sketchy.

In corresponding with a friend recently, I started thinking about how we look at the quality of medical evidence, and how we can communicate this to the lay public.

Let’s take, for example, cholesterol.

It has been found over the years that there is a strong association between elevated cholesterol and coronary artery disease. Through many studies, it was found that LDL cholesterol is a useful marker of cardiac risk due to elevated cholesterol. Finally, it was found that lowering LDL cholesterol, especially with statin drugs, dramatically reduces heart disease risk and mortality.

That’s the facts. But what are they based on? How strong is the evidence?

Evidence-based medicine has many ways of grading quality of evidence. The primary reference for cholesterol treatment in the U.S. is the National Cholesterol Education Program’s Adult Treatment Panel III (NCEP and ATP III).

Before the report gets to any recommendations, it presents a table explaining how evidence used in the report is graded. First is the type of evidence (from randomized controlled trials down to clinical experience) then is the quality (from “very strong evidence” to “strong trend”).

For example, the ATP gives the following recommendation (among many):

Evidence statements: Secondary prevention trials demonstrate that reduction of LDL-cholesterol levels significantly reduces risk for recurrent major coronary events in persons with established CHD (A1).

That “A1” at the end gives an idea what kind of evidence we’re working with. In this case the statement is based on RCTs and there very strong evidence to support it.

Evidence-based medicine is about evidence. Sometimes that evidence is quite good, sometimes it isn’t: the quality of evidence is something we take into consideration when treating patients.

This is in stark contrast to so-called alternative medicine. Alternative medicine never discusses quality of evidence. The quality is usually, however, quite poor, relying on patient and physician anecdotes, uncontrolled “trials”, and fantasy.

Making use of EBM doesn’t have to be difficult. You don’t have to be able to interpret every chi-squared analysis, you don’t have to calculate every number needed to treat. You just have to be able to read the basic literature in your field, look up recommendations, and know how strong they are.

Anyone practitioner who ignores evidence-based medicine is not practicing the best of modern medicine. Anyone who treats disease without understanding the difference between evidence-based practice and non-evidence-based practice should hand you a Quack Miranda Warning when you walk in the door.

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Live forever!

Posted in Altie Meds, Denialism, Medicine by Skepdude on August 18, 2008

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Look, whether you like it or not, you can’t live forever. I bring this up because there is always a new book or new add purporting to have “the answer” to long life and good health, which never includes modern, evidence-based medicine. Still, perhaps some of these books contains good advice. Or not. Let me explain.

First let me disabuse some of you of the thought that doctors don’t “do” nutrition and life-style advice. In fact, we do. And as attractive as the idea seems, life-style modification will never be the answer to all of (or even most of) our medical problems. Leaving aside the fact that many people cannot make permanent and beneficial changes in their life-styles, there are many other reasons. Human health and disease is complex. Most diseases are multifactorial. For example, type II diabetes is caused by a combination of genetic factors and diet. Some patients can remain off medication using diet and exercise. Some cannot, as even with a good body mass index, good diet, and good exercise habits, their blood sugars are still out of control. Another example is hypertension. Dietary sodium reduction has been shown to reduce blood pressure, but many patients will not have significant enough improvements in blood pressure through diet and exercise alone.

Another reasons that lifestyle changes aren’t the whole answer is that sometimes drugs provide benefit that diet and exercise cannot. For example, beta blockers reduce blood pressure, but they also prevent sudden and premature death in certain groups of patients (i.e. those with significant heart failure), independent of the effect on blood pressure.

Finally, many purely genetic diseases are not amenable to lifestyle modification. No amount of diet and exercise will fix cystic fibrosis or congential adrenal hyperplasia.

Living healthy is important, but there is no miracle to maintaining health and treating disease. No one book is going to help you live forever. Lifestyle modification is not the answer to every medical question, no matter how much we all wish it were.

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$30M in Fines for Scam “Created by a Teacher”

Posted in Denialism by Skepdude on August 15, 2008

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The FTC has piled on Airborne, one of the most annoying consumer scams in the market. The vitamin pill was advertised to prevent colds. And it was created by a teacher! But the FTC concluded:

…there is no competent and reliable scientific evidence to support the claims made by the defendants that Airborne tablets can prevent or reduce the risk of colds, sickness, or infection; protect against or help fight germs; reduce the severity or duration of a cold; and protect against colds, sickness, or infection in crowded places such as airplanes, offices, or schools.

If you’ve ever bought Airborne, you can collect on the settlement by visiting http://www.airbornehealthsettlement.com/.

One interesting aspect of the FTC settlement is that at least one of the agency’s five Commissioners thinks the remedy is too weak. Commissioner Rosch wrote in a dissenting statement that:

…I believe that the Order provision allowing the defendants to deplete their existing inventory of paper cartons and display trays until October 31, 2008 will continue to perpetuate misperceptions about the products’ ability to prevent or reduce colds…I also believe that the Complaint and the Order should address claims on the current packaging that assert that the product has “immune-boosting” qualities. Finally, and most importantly, it is my opinion that the only way to effectively remove these lingering misperceptions about the qualities of the Airborne Health Products would be to require the defendants to engage in corrective advertising. Therefore, I respectfully dissent.

Amen! Why let them continue to sell off their bogus products? And I wonder whether $30 million is enough to discourage this behavior? They very well could have made more than that on the unsubstantiated anti-cold claims.

Now it’s time to go after Airborne’s scam competitors, Walgreen’s Wal-Borne and Air Armor.

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Galileo, Semmelweis, and YOU!

Posted in Denialism by Skepdude on August 11, 2008

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To wear the mantle of Galileo, it is not enough to be persecuted: you must also be right.
–Robert Park

I used to spend a lot of time on the websites of Joe Mercola and Gary Null, the most influential medical cranks of the internets (to call them “quacks” would imply that they are real doctors, but bad ones—I will no longer dignify them with the title of “quack”). I’ve kept away from them for a while in the interest of preserving my sanity. Unfortunately, Orac reminded me this week of the level searingly stupid and dangerous idiocy presented by these woo-meisters.

In light of this, it seems reasonable to reexamine the Galileo gambit. When a “discoverer” of some new medical “miracle” is dismissed by the medical establishment, they often invoke the ghosts of Galileo and of Ignaz Semmelweis.

Galileo and Semmelweis are a pair of historical figures that share a common story—they both made significant scientific discoveries, documented the evidence for them, and were reviled by certain authorities, but eventually honored.

Ideas are cheap. I believe that my idea to use a flow sheet to track my diabetics’ care leads to better outcomes. I have precisely NO evidence to prove this, but it doesn’t harm me or my patients, and there is at least peripheral evidence elsewhere that this is a good idea. There is also a plausible hypothesis behind this—if I have one piece of paper that contains the critical data for a diabetic, I can see right away if their blood pressure or cholesterol are above optimal levels, I can see what their weight is doing, and I can see if they have engaged in proper preventative care, such as eye and foot exams. There is also a small body of data to support the practice. It would not surprise me if someone studies this in the future and finds my method lacking, especially vs. electronic health records. When necessary, I’ll happily modify my practice in a way that benefits my patients.

Let me summarize the characteristics of a “good” clinical science thinking, in this context (no, I’m not gonna go all Popper on y’all):

    Relevance: an idea should bear directly on a real clinical problem
    Testability: it should be possible to test the idea to see if it has merit (this includes Popperian falsifiability).
    Plausibility: the idea should have some basis in reality and should not have been birthed de novo from between someone’s buttocks. It should not require a “suspension of disbelief” or “open-mindedness”.
    Abandonability: the poser of the question should be willing to abandon the idea if it is proved false. Moving the goal posts, invoking a conspiracy, or any other deus ex machina is never necessary for a good idea.
    Modifiability: an idea can be rationally modified and retested if it may still contain a kernel of truth despite failing one or another tests. Any idea that is held so tightly that reality must be modified to fit the idea should be highly suspect.

There is an enormous literature on what constitutes science, etc. This is just a little guide to reading on quackery, crankery, and other idiocy.

When you encounter possible medical crankery, a couple of questions to ask yourself are “cui bono“: who benefits? Is the answer “patients”, “medical science”, or “one dude with a P.O. box”?

The other question is, “where’s the evidence?” (remember, no conspiracy theories or you violate Pal’s Law).

Or, as Dawkins so acerbically put it:

If you are in possession of this revolutionary secret of science, why not prove it and be hailed as the new Newton? Of course, we know the answer. You can’t do it. You are a fake.

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Conscientious objector or deserter?

Posted in Denialism, Medicine by Skepdude on August 4, 2008

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The discussion we’ve had since Friday regarding the Bush administration’s latest foray into theocracy brought up some interesting points. We discussed implications of the draft regulations including likely limitations on access to safe and effective birth control. But there is another issue here that disturbs me greatly.

Last week we talked a little bit about medical ethics. I’m not an Ethicist (Mike! Are you reading?), but I am a “practical ethicist”, as are all health care providers. How do ethics inform the discussion of what care we can or cannot provide?

First, let’s take the gloves off for a moment. What is a “pharmacist”?

A pharmacist is a trained professional with an expert knowledge of medications. In the retail setting, their primary role is to dispense medications, but their actual role is far greater. Pharmacists check patients’ records for drug interactions, counsel patients on how to properly store and take medications, and communicate with doctors regarding potential problems with prescriptions. Pharmacists are not, in most settings, the patient’s clinician, and do not have the same type of (ethical) relationship to their customers as doctors do with their patients. They are, at the simplest level, technicians and scientists who help maintain the safety and integrity of patients’ medications. It is a great responsibility—one small mistake on the part of a pharmacist can kill, and one small mistake caught by a pharmacist can save a life.

When a pharmacist receives a prescription from a physician that they believe may pose a threat to a patient, they call the doctor. For example, if I were to write a prescription for levothyroxine 125mg daily, the pharmacist would call me up to see if I meant micrograms rather than milligrams (125 mg is a helluva lot of this drug). If I tell the pharmacist to shut up and dispense the damned drug as written, they might refuse to pending further research, discussion, etc. This often happens with opiates. I may prescribe a cancer patient a very large dose of morphine and the pharmacist will call me to confirm. I’ll explain that they have been on this dose and tolerated it well, and the pharmacist will likely be satisfied that I know what I’m doing.

A pharmacist that receives a properly written prescription for a medication that any reasonable doctor would consider safe may not ethically refuse to fill it. The doctor and patient are the ones who make the decision on what meds are proper. In this case the pharmacists only remaining job, after checking for allergies and drug interactions, is to fill the legal prescription. If they don’t wish to do that, they should be fired, just as the check-out clerk would be fired for refusing to ring up a candy bar (and no, it doesn’t matter how fat the customer is). It has come up frequently that pharmacists sometimes refuse to fill birth control pills. This is unconscionable. The doctor and patient have a clinical relationship; the pharmacist in this instance is an intermediary, and could theoretically be replace by a sophisticated vending machine. Hmmm….

__________

The relationship between physician and patient is a bit more complicated. There is an asymmetry in the power relationship—anything the doctor says and does is potentially coercive. The doctor and the patient both count on this asymmetry—a patient goes to the doctor for advice, a doctor hopes their position of authority will help persuade the patient to do what is necessary (more on this issue of autonomy vs. paternalism here).

If a doctor tells a patient that smoking is dangerous, the patient is likely to believe them and will treat the words differently than if they had come from someone else. The same goes for a doctor’s opinions. If I tell my patient that I love Obama and that voting for McCain would ruin the American health care system, I’m probably using my influence in a bit of a shady manner. If a young woman comes to me wishing to terminate a pregnancy, and I tell her it is tantamount to killing a child, it means something very different to her than if she sees it on a billboard. If I oppose abortion, and feel I wish to be a “conscientious objector”, to share that with the patient is no longer an act of conscience, but an act of coercion. It is a desertion of my duty as a physician. I have patients who are Jehovah’s Witnesses. I give them very detailed information about the medical (not moral) consequences of their beliefs, but I stop there.

Doctors are activists—activists for the rights and needs of our patients, to which we subsume our own values to a great extent. This is one of the great challenges of medicine, and if you’re not up to the task, it’s time to get out.

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