Respectful Insolence

Here and elsewhere in the blogosphere, over the last several years, what started out as a more general interest in skepticism and science with a natural focus on medicine and a side interest in combatting Holocaust denial became more focused on promoting science-based medicine. As the saying goes, "Science, it works, bitches," and I make no apologies for promoting science-based medicine as the best medicine and applying skepticism and science to claims of purveyors of unscientific so-called "alternative" medicine advocates and anti-vaccine loons. However, I am not blind to the shortcomings of SBM, the claims otherwise of those who really, really don't like me notwithstanding. I've even written about them right here on this very blog (and elsewhere). However, I continue to steal ruthlessly from Winston Churchill when he said, "Many forms of Government have been tried and will be tried in this world of sin and woe. No one pretends that democracy is perfect or all-wise. Indeed, it has been said that democracy is the worst form of government except all those other forms that have been tried from time to time."

The same thing goes for SBM. It's the worst form of medicine--except for all those other forms that have been tried before. (Look for some enterprising woo-meister to quote mine that passage.)

One of the most important aspects of SBM--actually all of science--is the peer-reviewed scientific literature. There, scientists report their findings, after they have been subjected to peer review, for other scientists to examine, replicate and expand on, and, quite often, attack ruthlessly. It is through a ruthless, Darwinian selection process that poor science is either overturned or forgotten and good science is confirmed and expanded upon to use as a basis to improve upon. This process is incredibly messy, particularly in medicine and particularly to lay people who are not used to the rather nasty testing to which scientists naturally subject each other's work to, which is perhaps one reason why alt-med advocates often have a hard time handling scientific criticism that is actually not even particularly harsh. Be that as it may, SBM can be quite frustrating in that it may take much longer than one would expect to change in response to new evidence, but if there's one thing that distinguishes SBM from woo is that it actually does change in response to evidence, casting aside therapies that do not work or do not work as well in favor of therapies that work better. The peer-reviewed scientific literature is how that new scientific information is distributed to physicians. If the peer-reviewed scientific literature is corrupted, then the information that physicians receive is corrupted.

Yesterday, I was depressed to see Steve Novella take on a Policy Forum article in PLoS Medicine by Adriane J. Fugh-Berma of the Department of Physiology and Biophysics at Georgetown University entitled The Haunting of Medical Journals: How Ghostwriting Sold "HRT". Steve did his usual fantastic job of looking at the article and the practice of pharma ghostwriting, but I decided that I needed to comment on the article as well, mainly because of how related to my area of specialty it is. Hormone replacement therapy (HRT) is a textbook example of how medicine can at times embrace a therapy before its' ready for prime time to the point that the therapy can even become the standard of care. It's also a topic I have discussed before in the context of HRT. Basically, the first time around I expressed my outrage at a particularly egregious example of allowing pharma ghostwriting on the topic of HRT. In particular, I could not understand how Dr. Gloria Bachman, professor of obstetrics and gynecology at the Robert Wood Johnson Medical School in New Brunswick, NJ, in essence allowed a minion of Wyeth Pharmaceuticals working through a company contracted by the pharmaceutical company to write a 14 page review article that Bachman published almost unchanged in The Journal of Reproductive Medicine in 2005.

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I must admit that, after having taken it easy over the last few days, when the time came to sit down and get back into the swing of things, I had a bit of a hard time. No, it's not just blogging. That's actually a rather minor component of the whole malaise that descended upon me like a shroud. Rather, it's the simple fact that the Labor Day weekend in the U.S. represents the unofficial end of the summer season. After that, it's all back to school, back to work, back to the grind.

Back to real life after summer.

This reluctance, not surprisingly, seeped out of real life and started to permeat blog life. What I needed was something to get me going again with enthusiasm. For a moment, I wished I had held back my post from Sunday, because, despite (or perhaps because of) its being uncharacteristically brief for me it was actually one of my better posts. Fortunately, though, for skeptical bloggers, particularly those who have made the depredations of the anti-vaccine movement one of his favorite topics, there exists a gold mine of anti-vaccine woo that almost never fails to provide fresh meat blogging material for a skeptical blogger to sink his teeth into. There, although there are several bloggers, there is one who is capable of illustrating the arrogance of ignorance better than any other. Yes, I'm referring to Age of Autism as the blog, and the blogger is Mark "Not a Doctor, Not a Scientist" Blaxill, who yesteray was crowing There's a Funny Thing About Evidence: More Support for Autism-Mercury Link. Let's just put it this way. There is a funny thing about evidence. It's just not "funny" in the way Blaxill thinks it is, as the entire AoA crew will find out in the near future and about which I can't say more--for now.

In the meantime, let's take a look first at what Blaxill says about the study that he is presenting as "evidence" that thimerosal in vaccines causes autism, and then at the study itself. It's quite amusing to see someone so talented at so thoroughly deluding himself:

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After chilling out for part of the weekend, yesterday I became so engrossed in writing my part of a training grant for my postdoc that, before I knew it, it was way too late to provide you with the Insolence you crave for today. Oh, well. Tomorrow for sure; there's a lot that has been waiting for my attention. Besides, I haven't even really taken a vacation this summer; so I deserve a day or two (or three) off from time to time. In the meantime, I'll post a couple of bits of "classic" (if you can call it that) Insolence. This particular bit of insolence dates back nearly four years, all the way back to November 2006. Remember, if you haven't been reading at least four years, it's new to you! Besides, it's always fun (or disturbing) to me to see how well some of my older material has aged. See you tomorrow. Unfortunately, nothing appears to have changed since I first banged this out on my keyboard. Maybe I should do an update.

If you're a physician, there comes a certain point in your career when you start caring a lot more than you did about the next generations of physicians in the training pipeline. While you're in the middle of training, you are the next generation; besides, you're too worried about just getting through medical school, residency, and Board certification to be all that concerned about those behind you in the pipeline, anyway. Then, when you're early faculty, you're concerned about establishing yourself, getting your career on track, and, if you're in academics, getting promoted. True, physicians who aren't interested in education wouldn't be in academics in the first place, but most of us tend to be far more concerned about resident education, because these are the people who will be replacing us one day in our own specialties. At some point, however, one starts wondering about the next generation of doctors that will not just be replacing one's own specialty, but will be becoming the next generation of primary care doctors, internists, and other specialties aside from one's own. Part of this interest in self-interest. After all, we're all getting older, and aging physicians will need doctors too. More importantly, though, most physicians like to think that their profession is improving and that the next generation of physicians will surpass the present generation, thus insuring continued improvements in the science and art of medicine. We like to see our generation leaving a legacy of improved patient care and part of that legacy is the training of medical students.

Unfortunately, I have seen what may be the future of American medicine, and now I'm very concerned. Dr. R. W. has shown it to me. The American Medical Student Association (AMSA), an organization that should be committed to advocacy of the finest training and the best scientific medicine, is deep into promoting woo among medical students.

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After chilling out for part of the weekend, yesterday I became so engrossed in writing my part of a training grant for my postdoc that, before I knew it, it was way too late to provide you with the Insolence you crave. Oh, well. Tomorrow for sure. In the meantime, I'll post a couple of bits of "classic" (if you can call it that) Insolence. This particular bit of insolence dates back nearly four years, all the way back to November 2006. Remember, if you haven't been reading at least four years, it's new to you! Besides, it's always fun (or disturbing) to me to see how well some of my older material has aged. See you tomorrow.

A few days ago, I posted a response to another physician who was not happy with me, no, not happy with me at all. What made him unhappy was the vociferousness with which I criticized the creeping infiltration of woo that is insinuating itself into medical school curricula and expressed dismay at the threat that I see to evidence-based medicine (EBM) from it. He interpreted this vociferousness as "anger," but in reality it is more frustration, a dismay that was exacerbated by his defense of including unproven therapies in his practice. I did not respond so harshly somuch because I think that in his specific case his use of acupuncture does harm, but rather because of the attitude behind it, an attitude that can (and in too many cases does) open the door to less benign forms of woo.

At the risk of turning this into the Solo Practitioner rebuttal blog, I thought I'd have one more go at it because of one further comment he made. SP's misguided analogy does, almost in spite of itself, bring up a a difficult issue, although I resent it a bit that he did so in the context of labeling me and those who have little tolerance for woo as "fanatics":

Let's talk about false hope. Apparently "conventional" medicine is immune from providing this to its patients; however, a study a few years ago found that less than 50% of terminally ill patients with cancer at one of the nation's leading cancer centers, Memorial Sloan-Kettering Cancer Center, were approached with discussions about end-of-life issues, such as a DNR (Do Not Resuscitate) order and a Living Will. Furthermore, most of the therapies used for terminal cancer patients at MSKCC are not EBM, because there hasn't been enough time to study the efficacy of these therapies, or perhaps because these "conventional" doctors have decided that there is little "harm" that can be done with potentially toxic chemotherapy if the person is going to die anyway (as long as the patient consents to a potentially toxic, life-threatening treatment. But what would make a patient consent to such an unproven treatment? Could it be that it provides some hope of a cure?). It seems these doctors believe that they can try experimental, unproven therapies because these patients come to them from other referral centers where their cancers were determined untreatable. These patients are coming for another answer and for HOPE. So are these doctors at MSKCC "quacks" for slipping outside the confines of EBM to try to help the terminally ill? According to Orac, it sounds like no other medicine should be practiced other than EBM.

"Sorry, you've got Stage IV Ovarian CA, go home, get your affairs in order and die, because there are no evidence-based treatments that work," is perhaps what they should tell their patients. That way we're all living in realityland. How is it ok for "conventional" medicine to expose these patients to harmful, toxic treatments that are unproven? It doesn't stand up according to Orac's arguments.

Logical fallacies piled on top of nonsequiturs piled on top of straw men. These have to be dealt with before we get to the issue that he brings up almost by accident, namely the ethics of clinical trials in which terminally ill cancer patients are enrolled.

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In case you hadn't guessed, because of the holiday weekend, blogging's been rather slow. This is in general a good thing, a chance to rest and rethink, but occasionally, even while chilling out, I see things that I can't resist mentioning briefly. Things like this.

If there's one thing about "complementary and alternative medicine" (CAM) that has always puzzled me, it's that, at least here in the "West," there seems to be an inordinate fascination with ancient "Eastern" medical systems. These include, of course, traditional Chinese medicine (TCM) and Indian Ayruvedic medicine, both of which are somehow viewed as "superior" to "Western" reductionistic medicine. Of course, some things that are often lumped together with TCM (for instance, reiki) are neither Chinese (reiki was invented by a Japanese man) nor ancient or traditional (although it's existed for centuries, acupuncture as we know now it evolved into its present form mostly in the 20th century, and reiki was first publicized in 1922). Be that as it may, this fetishism of all things "Eastern" by many in the CAM movement leads me to considerable amusement when I see a story like this one, which somehow I missed when it first appeared about a week ago, entitled Japan's medical authorities slam 'absurd' homeopathy:

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One of the most frustrating aspects of taking care of cancer patients is that in general, with a handful of specific exceptions, we do not have good curative therapies for patients with stage IV cancer, particularly solid tumors. Consequently, we are forced to view patients with stage IV cancer as "incurable" because, the vast majority of the time, they are incurable. Over the years, we have thrown everything but the kitchen sink at patients with stage IV disease, largely with dissapointing results. That's not to say that the few specific exceptions to which I alluded are not a reason for hope. After all, patients with colorectal cancer and liver metastases used to have a median survival of around 6 months, but these days, with newer chemotherapeutic regimens like FOLFOX plus Avastin, median survival has more than tripled. While expecting to live less than two years is cold comfort to cancer patients with this particular clinical situation, the prognosis is far better than it was.

Of course, I specifically mentioned Avastin because it's been in the news a lot recently with respect to my area of clinical specialty, breast cancer. Specifically, beginning in July there started appearing a spate of stories about the FDA considering revoking the approval of Avastin for advanced breast cancer based on recent studies that demonstrate that it does not prolong survival in these patients. Many lay people and patients find this reconsideration of Avastin to be quite puzzling, given that the drug was granted accelerated approval in 2008 and has since gone on to be used fairly widely. Given that the case of Avastin in breast cancer is rapidly becoming a classic case study of how messy science-based medicine can be when practiced in the public eye and debated among pharmaceutical companies, the government, and patient advocacy groups.

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