Sunday, June 01, 2008

Ducks unlimited

It's one thing when the man and woman on the street trips and makes a logical booboo. It's brow-raising and elicits incredulity when someone with acronyms suffixed to their name commits a rudimentary fallacy.

Woodson Merrell, MD is a "board member of the New York State Office of Professional Medical Conduct, a member of the American College of Physicians, American Medical Association, New York State Medical Society, and New York County Medical Society, and an Assistant Clinical Professor of Medicine at ... the Columbia University College of Physicians and Surgeons." You'd think that with such stature he'd know better than Tom, Dick and Harry. Unfortunately, Merrell is into "integrative medicine" otherwise known as complementary and alternative medicine (CAM), a phenomenon that before its marketing makeover was known simply and unobfuscatedly as quackery.
The same set of practises that was called quackery or fringe medicine in the mid twentieth century was renamed "alternative medicine" in the 1960s and 70s. The term "complementary medicine" was coined during the 1990s.... Further rebranding has given rise to the notion of "integrated medicine." (Rose Shapiro, Suckers: How Alternative Medicine Makes Fools of Us All, London: Harvill Secker, 2008, p. 1)

However, Merrell's plunge into quackery isn't the error I'm referring to. James Randi reports that, "In an interview with the American Pain Foundation, Merrell said:"
We use whatever is safest, gentlest, and most effective for the patient regardless of what tradition it came from. As much as possible, we use an evidence-based approach, but certainly would consider an herbal remedy that's been around for twenty-five hundred years – that's a significant enough empirical trial.

Merrell was already was on track with the "effective" and "evidence-based" bits, but that last clause sabotaged his entire credibility. Given his argumentum ad antiquitatem, it may be that he doesn't really understand what evidence-based medicine is about, why randomized, double-blinded, placebo-controlled clinical trial (RCT) is the gold standard of medical research, that bias is the number one enemy of objective testing and that the twenty-five-hundred-year "empirical trials" he's alluding to are precisely loaded with such biases.

James Randi elucidates on the fallacy. He's addressing Merrell:
Doctor, the idea of a Flat Earth has “been around” far longer than that, and was tested countless times; the Earth always looked flat, everyone knew that! The fact that a really bad idea has been around for centuries, doesn’t make it correct, it only makes it old. Yes, many, many, herbal remedies work very well, and were discovered by experiment, long ago: digitalis, aspirin, so many remedies we still use today. But we don’t use them because they’re old, we use them because they’ve passed the “evidence-based” trials that you mention are advisable when “possible.” For half a century, calomel was raved over as a cure for just about everything, and doctors prescribed it freely – until they noticed that not only the ailment went away, so did the patients. They died from mercury poisoning, because calomel is mercurous chloride…

In the same issue of Swift, Randi shares with us yet another fallacy (an epistemic one) from the producer of the television program "Healthcast." In one of its episodes the show featured Tong Ren (Chinese origin perhaps?), a quack treatment that essentially consists of "tapping on a doll with a small hammer." After seeing the show, a skeptic wrote and complained to producer Laura Stebbins. As part of her reply she wrote:
Hundreds of people from all over the world have testified that this therapy has helped them...

Hundreds of people have also testified that arsenic, bloodletting, cupping, Laetrile, healing touch, ... have helped them. But there is no objective evidence that any of these are effective. In fact your eyes probably (and rightly) popped when you read "arsenic"--some things that people swear by are in fact downright harmful. Actor Steve McQueen availed of Laetrile (among other snake oil) for his cancer, and yet Laetrile contains a non-insignificant amount of cyanide.

Perhaps Stebbins is unaware that a thousand testimonials is as good (or bad) as a single one. There are very good reasons why the FDA and medical researchers don't accept and don't rely on testimonials or even case studies as evidence for the efficacy or safety of any treatment modality. They are so laden with confounding factors (including the biases we talked about above) that anecdotes are completely useless as evidence. At best they are starting points and incentives for further research.
If one person can commit the fallacy of false cause, so can a hundred. If one piece of evidence is invalid or unreliable, many more pieces of invalid or unreliable evidence don't make the case any stronger. This means that the many testimonials offered by practitioners or users to promote a favorite therapy generally don't prove much of anything--except perhaps that some people have strong beliefs about certain treatments. (Theodore Schick, Jr. & Lewis Vaughn, How to Think About Weird Things:Critical Thinking for a New Age. Mountain View, CA: Mayfield, 1999, p.203)

In other news, Yale University is going to the ducks. It now has an Integrative Medicine program and in April held its first annual Integrative Medicine Scientific Symposium. I think there must've been a typo there. They must've meant "Ist Annual I.M. Pseudoscientific Symposium." There! Now we've done away with the oxymoron.

I'll have Dr. David Colquhoun introduce the premier woowoo during the symposium.
David Katz, MD, MPH, FACPM, FACP, is founder and director of the Integrative Medicine Center (IMC) at Griffin Hospital in Derby, Connecticut. He is also an associate professor, adjunct, of Public Health and director of the Prevention Research Center (PRC) at the Yale University School of Medicine in New Haven, Connecticut.

That sounds pretty respectable. But he is into not just good nutrition, exercise, relaxation and massage, but also utterly barmy and disproved things like homeopathy and ‘therapeutic touch’.

In his talk, Katz rallied for a "more fluid concept of evidence." In other words do whatever is necessary to make sure that candidate modalities that flunk the exam still get to graduate and be certified. This includes accepting case studies and anecdotes as objective evidence for efficacy. In his speech Katz brings up various treatments (e.g.., CoQ10, vitamin therapy, homeopathy) and the lack of solid hard evidence for them and yet he defends them--lamely--with the aphorism "absence of evidence is not evidence of absence." Indeed if I can't see radio waves it doesn't mean they aren't there. However, if treatment X is in fact ineffective then there's nothing else to witness but absence of efficacy! (Likewise with any other claim: if Y doesn't exist and isn't real then you won't find any evidence for Y.) Needless to say, believing that X works (or that Y is real) until good evidence is at hand is unwarranted.

Colquhoun on Katz's speech:
Dr Katz goes through several different trials, all of which come out negative. And what is his conclusion? You guessed. His conclusion is not that the treatments don’t work but that we need a “more fluid concept of evidence.”

Dr. Steven Novella summarizes the Katz approach: "When studies of 'alternative' modalities are negative, proponents want to change the rules after they see the results." When former Chair of the Society of Homeopaths Felicity Lee was asked why she still practices homeopathy after the best studies have shown it to be no better than placebos, Lee replied that science and RCTs aren't suited to testing homeopathic remedies (although when questioned as to why this is so, Lee was stumped).

On the other hand, should a battery of independently performed RCTs unquestionably show that the modality works, the quacks would accept the robust design and methodology and hail the trials as definitive proof. In other words, these CAM and IM practitioners want to have their cake and eat it too. They want to keep their belief whether the evidence is positive or negative. I find psychiatrist M. Scott Peck's observation of psychiatric inmates cogent. According to Peck, in effect these people say, "Don't disturb our delusions." Merrell, Katz, Lee, and other proponents are not loonies. But they're certainly grossly deluded (clinically defined as continuing to believe even in the face of overwhelming rational arguments/evidence to the contrary).

In the same talk Katz describes medical schools' emphasis on evidence as indoctrination. Colquhoun calls this "a pretty graphic illustration of his [Katz's]deeply anti-scientific approach to knowledge." It can't be emphasized enough: there is no other way to test the efficacy of therapeutic modalities except through scientific means, the best and most reliable being the RCT.


Anonymous said...

I wish the medical community would subject itself to the same standards of scientific rigor they want to impose on “alternative” therapies. My mother died in the hands of doctors who were constantly prescribing drugs with horrendous side effects — some of which were subsequently taken off the market. In addition, they were always suggesting some “experimental” therapy that was incredibly expensive and (of course) had no scientific testing. At least most of the alternative therapies I’ve heard about have less chance of causing liver and kidney failure than massive doses of prescription drugs.

Edwardson said...

Efficacy and testing for efficacy is one thing. Safety is something else. Let me clarify. Medical treatments/therapies need to tested to ensure that they are in fact effective, and more to the point, more effective than placebos. Comparatively speaking it's easier to determine whether some treatment X works better than a placebo or not, or whether it's better/worse than other current treatments (that already have been tested). But whether X is completely safe is another story. As you can imagine it's a onerous task testing its interactions with a variety of food and the plethora of other drugs. And mind you this is only one facet of a drug's safety.

You said that your mother had been treated with experimental therapies. You've got a chicken and egg problem here. How can you know that something will work and is really safe until it's been tested on actual humans, not just lab rats or rabbits? And how can you demand safety and efficacy when that's the very thing experiments are suppose to establish?

CAM on the other hand neither implements the rigorous testing (that is, employing tight controls ) for efficacy or safety that mainstream drugs are subjected to.

One wonders why the drugs you're alluding to were taken off the market. Did better ones come online? Were there adverse effects and safety problems with them that weren't detected early on? Were the drugs effective in the first place? Did they work against the condition they were targeted for? I gather from what you've said that they were.

The alternative remedies you allude to that don't have side effects are probably placebos. They just make the patient believe they've taken something that works. The heuristic in medicine is: the greater the potency of the drug, the more side effects you can expect.