Posts Tagged ‘Medicine’
Making the rounds last week was another example of the poor quality medical and science reporting that has come to saturate the mainstream media. The article in question, on the benefits of acupuncture for animals, is fairly typical. The situation appears to be rapidly worsening as more dedicated science reporters are being replaced with generalists, although as a skeptic I must recognize that a certain degree of selection bias may be coming into play. I do tend to go out and look for this sort of fluff pseudojournalism. But as I continue to read report after credulous and poorly researched report on topics like vaccine safety, alternative medicine, and even ghost or UFO sightings my expectations continue to steadily decline. If not for blogs like Science-Based Medicine and Neurologica, I feel I would have very few places to turn. I do like to tell myself, in an attempt to feel just a little better about the current state of affairs, that the blame falls primarily on inexperienced journalists, but even seasoned reporters with significant exposure to scientific topics are dropping the ball, as was the case in E.J. Mundell’s March 3rd HealthDay News report.
According to his bio, Mundell, the Senior Assigning Editor for HealthDay News, has 10 years of experience writing (among other things*) on health related topics for a variety of outlets such as Reuters Health and The Scientist. At one point he was even the managing editor for the consumer health news division for Reuters. Yet despite this experience, he penned a sloppy piece of pseudojournalism entitled Animals Respond to Acupuncture’s Healing Touch.
In the article, it is clear that Mundell did not seek out the scientific or skeptical viewpoint on acupuncture or its use in animals. But instead of the more common error made by journalists who, because of some seemingly pathologic need to provide a sense of balance, write as if there were two legitimate sides to a scientifically one-sided issue, Mundell has written what reads more like a press release from The International Veterinary Acupuncture Society. A vet who teaches one of their certifying courses is quoted in the piece along with a pro-acupuncture private vet and a “skeptical” pet owner who is amazed by her animal companion’s miraculous turnaround. There isn’t even the typical misquoted straw man one-liner from a skeptic included so that a believer might easily shoot it down. The two vets in the piece are allowed to spread blatant misinformation unchallenged. Why would Mundell write such thoroughly false information as if it were gospel truth and pass along such worthless anecdotes and testimonials?
There is so much wrong with this story that it is difficult to know where to begin. I think I’ll start, as so many reports on alternative medicine miracles do, with the standard anecdote about how a suprising therapy changed a patients life. In the article, Mundell cleverly describes the medical problems of a patient named Nelly in a way that is meant to fool readers into thinking she is human. Status post spine surgery, weak, lethargic and with poor appetite, Nelly’s friend takes her to a specialist for a seemingly last resort attempt at recovery. After just a few sessions, Nelly the dog is restored to her vibrant former self, all thanks to acupuncture. That’s right, animal acupuncture.
“Almost immediately after the first treatment, Nelly’s energy went from zero to 100,” recalled that friend, Annie Washburn, who works as a community organizer in New York City. Nelly became more mobile, ate more and resumed regular bowel movements. “She bounced back in a way that seemed miraculous,” Washburn said.
This anecdotal experience is unreliable and unable to effectively establish that Nelly truly experienced any improvement secondary to the acupuncture. In the many months that have passed since those initial treatments, Washburn’s memory could easily have been altered over time by multiple retellings of the anecdote. Also, humans tend to exaggerate positive outcomes over time. In reality, the actual events could have been very different than what we are being told without Washburn actually lying. All memories, even those that have evolved over time or were implanted by another person, feel real to us. And the more dramatic a so-called flashbulb memory is to us, the less likely it is going to be accurate weeks, months, and years down the road. This is why we are such poor medical historians and a big part of why properly designed studies are necessary to answer questions regarding efficacy of treatments.
What is more plausible is that the dog improved slowly over time and would have recovered eventually regardless of what therapy was being provided. Many proponents of inert therapies make a fuss over animals as patients because of their supposed inability to be effected by placebo. This notion is entirely false, however, as the placebo effect does have an impact on animals as well as on the owner’s perception of their pet’s recovery. The primary error is in thinking of the placebo as a single entity, that being some kind of mind-over-matter effect stemming from the expectation of the patient. If that were the case, then I would agree that animals are not susceptible to placebo. But that is a straw man manifestation of it. Instead of simply being mind-over-matter, the placebo effect consists of a number of different components, some of which are pure artifact, which can lead to the appearance of a true improvement. Among these components are the tendency for symptoms to regress to the mean, which is probably the largest component of any placebo effect, investment justification, a novel therapy or more complicated therapy effect, or the desire to please an authority figure to name just a few. None of these have anything to do with an actual physiologic effect from the intervention and they only require the pet owner’s biased and subjective personal experience.
It is easy to imagine how a dog lover might interpret their pet’s behavior differently secondary to a placebo effect. It usually takes Rosco a whole week to get over his flare ups but with acupuncture it only takes 7 days. In addition to pet owners and the potential for biased evaluations, it is equally easy to see how an animal might act differently because of how their owner interacts with them. Rosco might actually act more energetic and appear to be feeling better simply because his owner is paying more attention to him in anticipation of a postive therapeutic result. Perhaps other changes, like an improved diet or a new and more interesting location, may lead to positive changes in behavior that do not stem from any new therapy. It is foolish to think that the placebo effect can’t be applied to animals, particularly our doting animal friends.
The article is overflowing with misinformation and contains the expected pseudohistorical mention of how acupuncture is an “ancient healing technique.” Perhaps I employ too narrow a definition of the word, but I would not consider a therapy that has in reality only been practiced for at most a few hundred years as ancient. It is a commonly accepted myth that acupuncture as we know it has existed for thousands of years. I’ve even read one source which claimed that acupuncture dated back to the dawn of man. I have to wonder where our primitive primate ancestors would have acquired not only the steel used to fashion such thin needles but also the paper upon which to bill insurance companies for their use. According to Mundell,
“Experts point out that animals have been treated with acupuncture therapy from the very beginning. In fact, Chinese records that go back thousands of years describe the use of healing needles on horses and other livestock.”
This is simply false. Needle like instruments considerably larger than what are used today were used to drain pockets of infection in animals but there is no historical record from that time period of the placing of thin needles in special areas of the body in order to remove obstructions to a mystical healing energy force. This concept, as mentioned above, is probably only a few hundred years old and did not even become popular in China until the 1960’s when it was forced on the public by their government. And it has become steadily less popular as scientific medicine has come to play a larger role in Chinese society.
Mundell further reveals his ignorance of the subject, or perhaps his purposeful covering up of the rather silly underlying mechanism claimed by acupuncture believers, in the following explanation.
“The points, referred to as loci, represent important locations for nerves and blood vessels that, when manipulated, somehow aid healing, experts say.”
Acupuncture, as it is promoted by the near totality of practitioners and patients, involves the shoving of thin needles into specific points on the body in order to relieve the obstruction of a vital, yet undetectable by any modern scientific techniques, energy force. There is no legitimate evidence, anatomic or otherwise, that these loci have any special relationship to nerves or blood vessels. They are, in fact, completely arbitrary. There isn’t even agreement over the number or location of these loci, or over which should be focused on. Some proponents claim that only the ear requires needling while others only care about the bottom of the feet.
One of the experts in the article reveals that “veterinary acupuncture has proven effective in healing or easing the symptoms of arthritis, acute injuries, hip dysplasia, respiratory disorders, immune system ailments and a host of other problems” This is also entirely false. There have been, over the years, a number of small and poorly designed studies, typically unblinded and uncontrolled, that have shown a weakly positive effect. But, as is the case with inert therapies, as larger and better designed studies are performed, particularly studies that are appropriately blinded and have a placebo control group, it becomes increasingly evident that there is no effect. This is certainly the case with acupuncture.
Animal acupuncture is only one very small step above pet psychics on the list of the most absurd jobs in the pseudosciences or the paranormal.
* E. J. Mundell was the production secretary for 1990’s Prom Night III: The Last Kiss
One of the more common approaches that attending physicians take when teaching medical students and residents is the use of clinical pearls. Rather than cold, hard facts, such as the most common form of congenital adrenal hyperplasia being 21-hydroxylase deficiency, these pearls of clinical wisdom are more akin to generally accepted rules of thumb. My personal favorite example is the admonition to avoid poking the skunk. Poking the skunk occurs when labs are ordered which aren’t necessary in the care of the patient. Checking a basic metabolic profile when all you really need is the serum sodium is risky. In fact, it seems that the less vital a particular lab value is to management decisions, the more likely it is going to come back as falsely abnormal, which often leads to further unnecessary tests. I don’t like to stick needles in babies, although you might not think that if you spent a day with me at work, so this particular clinical pearl comes up pretty often on my rounds.
I also make a point, on an almost daily basis, to incorporate pearls of critical thinking into my teaching of medical professionals in training. Naturally, these tend to focus on my particular area of interest, the myriad and often contradictory therapies falling under the umbrella term alternative medicine. As I’ve said many times before, I prefer terms like unscientific medicine, or quackery to be quite honest, over alternative medicine, integrative medicine, or complementary medicine. These are manipulative marketing terms used to lull the general public into acceptance with a false air of legitimacy, and the academic community into the application of a double standard to the evaluation of safety and efficacy of these therapies. There is only one legitimate means of determining whether a treatment works, and that is with science.
One example of a very helpful critical thinking pearl that should be applied to the claims of a large number of so-called alternative approaches to health, is that there is often an inverse relationship between the number of symptoms or conditions supposedly treated by a therapy and the number that is actually treated. This is better expressed with the adage that if something is claimed to cure everything, it almost certainly cures nothing. The number of alternative medical modalities that fall into this category are numerous and experiencing seemingly exponential growth, however the most important example because of its acceptance by the general public as a legitimate and science-based practice is that of chiropractic.
Though nobody, even chiropractors themselves, have been able to define themselves in a way that allows a consistent and practical understanding of just what it is that they do, there are some safe generalizations which can be made. For instance, they tend to be spine-centered rather than the oft advertised “holistic”, and a significant percentage of them categorize themselves as “straight”. This distinction shares a dichotomous relationship with self-described “mixers”, which as the name implies are prone to incorporating a wide variety of decidedly non-spine centered therapies into their practice such as acupuncture, applied kinesiology, or nutritional supplementation, as well as some science-based modalities like standard physical therapy. Mixers outnumber straights by a large margin, and though they do make use of other therapies, they still primarily focus on the correction of a non-existant entity known as the subluxation.
Subluxations in the chiropractic sense, as opposed to the legitimate medical diagnosis, are as polymorphous as one would expect of something invented out of whole cloth* by a former magnet healer and spiritualist over a hundred years ago. Since 1895, the term has evolved into many different forms with all stages still believed in by varying numbers of chiropractors today. The manifestation which likely is accepted by the largest number of currently practicing chiropractors involves a proposed “complex of functional and/or structural and or pathological articular changes that compromise neural integrity and may influence organ system and general health”. This definition is so slippery as to be rendered utterly meaningless, and is a prime example of the inability of chiropractors to be able to establish a standard definition of who they are and what they do. This fact actually benefits chiropractors however, as it allows for a near limitless scope of practice and the ability to bill many insurance companies for the treatment of a phantom condition.
Regardless of whether a chiropractor is a straight or a mixer, they are likely to claim that they have special insight into your particular complaint regardless of what it is. With rare exception, chiropractors assert their ability to treat not just common musculoskeletal complaints, a category of conditions falsely considered by many to be their area of particular expertise, but the entirety of known medical maladies. Many will even treat one or more of a growing number of fictitious conditions such as adrenal fatigue or Wilson’s Thyroid Syndrome. This is often done overtly with outright claims of personal success in curing conditions ranging from asthma to zoster, with some even touting their ability to treat serious life-threatening illnesses like cancer and HIV.
Straight chiropractors take a different approach, boldly claiming only to treat subluxations, which then allows for the innate healing power of the human body to heal any disease state under the sun via an unimpeded spinal conduit. A critical evaluation of the medical literature reveals a far different reality however. After a little over a century of existence, there is essentially no good evidence that chiropractic care is effective in the treatment of any medical condition, or any made up one either. The one sliver of an exception is the treatment of acute lower back pain, which does appear to resolve under the care of a chiropractor. What they may not want you to know is that it has not been shown to work any better than more standard treatments such as physical therapy and the use of ibuprofen.
*The top link on google when inserting the phrase “invented out of whole cloth” takes one to an article on the history of chiropractic
Several news sources and blogs have recently reported on a study looking into the benefit of transcendental meditation (TM) in children diagnosed with ADHD. A January 5th report from Reuters Health, a news service which claims to be “internationally recognized as unbiased, authoritative, timely and dependable, with the reputation for quality that one expects from a Reuters company“, actually serves as a perfect example of how not to cover science or health news. With a skeptical mindset, a few minutes of spare time and an internet connection, I was easily able to discover the dubious reality behind this “landmark” research.
The study, led by “cognitive learning specialist” Sarina J. Grosswald, involved the instruction in TM techniques of 10 students previously diagnosed with ADHD and enrolled in a private school for children with learning disabilities. These students were followed over three months, at the end of which they were evaluated for improvement in a number of areas. According to the Reuters’ piece,
“After three months, Grosswald and her colleagues found, the students reported lower stress and anxiety levels, while their also improved, based on questionnaires given to teachers and parents.”
Impressive. For those who are confused, TM is a form of meditation developed by Maharishi Mahesh Yogi in the 1950’s which involves the repetition of a meaningless sound, or mantra, while sitting quietly with eyes shut. This allows the practitioner to quiet the mind and discover the “source of thought”. The mind and body are then able to achieve a state of calm and, according to proponents, reap myriad medical benefits far beyond that of simply increased peace of mind. Believers in TM have also been known to claim that an extension of the technique can lead to fighting crime with their minds and flying. I’m not kidding.
This is a pilot study published in a online education journal edited by graduate students, something which does no inspire confidence in me. I do not think that a reputable peer-reviewed medical journal would have accpeted it. At least the authors do admit in the discussion section that it would be inappropriate to make claims regarding a cause and effect relationship between TM and any improvement in ADHD symptoms based on these results. That doesn’t stop them from making bold statements regarding the benefit of TM, however, as I will soon get to.
The flaws in this study are numerous. The number of subjects is too small, there is no control group and it isn’t blinded. The study reveals that some of the children are on medication but it does not take into account the possibility of recent changes in medical therapy, or improved compliance while on the study. It is based purely on self-report and subjective questionairres and there is very high liklihood that a placebo effect could have been the sole responsible factor in the subjects’ apparent improvements. The authors then call for larger and better designed studies, something which I don’t think is justified for these reasons, but my problem with this study, and concerns regarding the credulous take by the media, go much deeper than what I’ve already explained.
What led me to dig deeper after reading the Reuters’ report was the following quote:
“The effect was much greater than we expected,” lead researcher Sarina J. Grosswald, a cognitive learning specialist in Arlington, Virginia, said in a written statement.”
I wondered why the researcher had expected an effect and hypothesized that there may be a connection between the researchers and TM more significant than academic curiosity. I was quickly able to discover that Grosswald is a hardcore believer in TM. Just read this quote by Grosswald from a website called Ask The Doctors, which provides a forum for specialists to answer questions related to TM and health:
“The TM technique is the exact opposite of harmful. It reduces your risk of getting serious chronic health problems like hypertension, diabetes, and heart disease. In fact, research on the Transcendental Meditation program shows that people who practice it go to the doctor about 50% less than the general population. And if they are in the hospital for some reason, their hospital stay is 50% shorter, on average. For some conditions, the need for medical care is as much as 87% less for TM meditators. Practicing the Transcendental Meditation technique is one of the best things you can do for your health.”
She clearly does not come across as an unbiased investigator. In reading her other responses on the “Ask The Doctors” website, and especially after listening to a 16-minute talk she gave in 2005, when this research actually took place, which is posted on a Maharishi Vedic Education Development Corporation sponsored website that focuses on “ADHD, the Mind and the Transcendental Meditation technique” called Insights in Health, it is obvious that she is a true believer. That doesn’t prove the research is bogus by itself, but it is a red flag.
A more concerning red flag, and one which was also discovered in the talk given by Grosswald, is the fact that the 10 children involved in the study may have been coached. In the last few minutes of the presentation, Grosswald presents clips of the children meeting with the TM proponents prior to the initiation of the study, where it appears that they are told what the expected outcome of the trial is, that their symptoms will improve with TM.
Not only are these kids aged 11 to 14 being told what the expected outcome of the study is by study investigators, the headmaster of the school, Linda Handy, can be seen at the very end of the video discussing how amazing the technique is and how it will change the students’ futures for the better. I am forced to question whether the teachers, whose evaluations of the study subjects’ behavior and performance are an integral component of the study conclusions of positive effect, might have been hesitant to give a negative evaluation when their boss is clearly also a true believer.
In the acknowledgments section, The authors thank the Abramson Family Foundation for funding and the Institute for Community Enrichment for support. The Abramson Family Foundation is an organization which believes that TM can help students achieve the full potential of their brain.
“The Abramson Family Foundation has been funding research on Transcendental Meditation and providing scholarships for students to learn the technique for the past 20 years. This has been a rewarding investment in the youth of our nation. Here is a common sense approach—a sound and scientific way—of fulfilling the purpose of education, which is to create intelligent, dynamic, happy, healthy and successful human beings.”
Of note, Grosswald sits on the Board of Advisors for the foundation. Joining her on the Board is none other than the school headmaster Linda Handy. Whatever doubt I had in my lack of enthusiasm for this study fell by the wayside upon that discovery. While it may not have been intentional on the part of the study authors, the school headmaster, or the pro-TM funding organizations, this study was designed in a way that coulnd’t possibly yield anything other than a positive result. And calls for further study, especially with public funds in addition to the over twenty million already spent by the NIH on TM, are unwarranted.
It wasn’t difficult to look at this study and see that the claims being made by TM supporters aren’t valid. It wasn’t even that hard to uncover the connections between the investigators, the school where the study was conducted and pro-TM organizations. Yet I was unable to find one news report that displayed even the slightest amount of critical thinking, instead reading like press releases from TM believers. The current state of science and health reporting is rather depressing, and I don’t see things improving any time soon as more and more dedicated science writers are falling prey to the poor economy.
It isn’t official yet, but I’ve now seen multiple news reports declaring that CNN’s own Dr. Sanjay Gupta has been chosen by President-Elect Obama as the next Surgeon General. The best I can come up with on this development is that it could be worse. I’ve never been impressed with him, and he has displayed a concerning misunderstanding of the vaccine-autism manufactroversy in the past. But at least it wasn’t Mehmet Oz, Andrew Weil, Deepak Chopra, Dr. Jenny McCarthy, etc, etc. We’ll see I guess. I’d like to see Steven Novella take on the position to be honest.