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29/02/2012 / Pedanto

Happiness Through Science

My friend Rob and I went to see Robin Ince’s Happiness Through Science show at the Stand Comedy Club tonight.

It was good.

Here’s the evidence:

An absolutely lovely bloke. If only a beardy man hadn't hijacked the conversation

I am happy.

14/02/2012 / Pedanto

A Little Less Education, A Little More Action Please

I like to bitch, don’t you know

I’ve been whining for a few posts now about how incredulous and uncritical the teaching of complementary and alternative medicine (CAM – if we add supplementation to this we have SCAM, a nicely plagiarised term) has been at my medical school. I can moan all I like, but it’s not exactly productive is it? So in that spirit, I thought perhaps a teaching resource might be useful.

If you are in medical education at Newcastle Medical School – I understand why I will not be graduating this year due to my professionalism. If you are from any other university or school and wish to use the following resources – feel free, but please contact me first as my fragile ego could do with the boost.

This is primarily aimed at medical students, but I think I think it unlikely that anyone with a reading age above 12 should have much difficulty with it.

So here it is for the first time ever – The Thewlis Ladder of SCAM. This should be taken as a primer for medical students on the subject of SCAMs and has borrowed heavily from Bad Science by Ben Goldacre and Trick or Treatment from Simon Singh and Edzard Ernst, with a smidgen of Mark Crislip’s Quackcast.

Disclaimer: Any similarity to categorisations of bullshit on the internet is purely coincidental.

Be warned – this will be a long blog post.

THE LADDER

The climb to the top has never been quite so stupid

The Much Less Than Ten Commandments

So, before I start I’d like to set down a couple of things that you really should consider when reading about any kind of medical treatment, new or old:

  1. Is there a plausible mechanism which fits with our current understanding of anatomy, physiology and biochemistry?
  2. Is the mechanism that’s being promoted based around “energy”? (a term I will come to later)
  3. Can it be shown under reasonable controlled conditions to actually work?
  4. Does it work either better, or similarly but with fewer side effects than other currently available treatments?
Please bear these in mind as we descend the ladder of SCAM together.

Magic

Magic refers to a SCAM so ridiculous that it in no way fits with how a materialist who believes in objective truth (yours truly) sees the world. It diverges completely from all understanding of science, and has been proven not to have any effect.

Reiki

Reiki involves the supposed manipulation of “energy” by either the laying of hands on a patient, or by the movement of hands above a patient.

Now here’s my comeback to the first things that most practitioners will say about reiki: “1922!!!!!“. I’ve been told it’s ancient before, but in fact it was developed in 1922 by Japanese Buddhist Mikao Usui. When you can’t even argue from tradition your new age hobby probably doesn’t have a leg to stand on.

The rest needs little explanation. Firstly, “energy” as often touted by new-agers far and wide is absolute and utter bollocks. Energy is not some strange ethereal shimmering light that seeps out of living things. Energy is a term used in physics to describe the capacity for work to be done. Heat, elastic potential, chemical, kinetic – this shit is energy! There has never been any demonstration that humans have any kind of energy field that can be manipulated consciously by another person. Anyone claiming they can manipulate your biofield with their hands is either a liar or deluded. Data? Here’s some! It has never been shown to have any effect for any condition….pretty damning no?

Homeopathy (or Homoeopathy if your really love them vowels)

I’ve previously covered the theory behind homeopathy but let’s review:

“In 1796 Samuel Hahnemann decided late one night, whilst sifting through his own excrement, that one of the especially tough corn kernels was justifiable inspiration for the unfounded assertion that “like cures like“. This “Law of similars” – as it has become known amongst the homeopathic community – states that if a substance can cause a symptom, once appropriately potentized, it can cure disease which exhibits the same symptom. For example, insomnia is often treated with potentized caffeine.

“Now how does one potentize a substance, one might ask. Well anyone with a pre-GCSE understanding of chemistry (a science with scientific laws – i.e. an assertion which can predict accurately the outcomes of scientific experimentation – not just words that sound nice together) would probably jump to the assumption that to make a substance more potent (whatever the fuck that’s meant to mean) one should probably try and concentrate it. Not so, sayeth the homeopath. Verily one must rail against the magicks of these modern sciences and instead do the opposite. Dilute serially that substance which you wish to impart with power, and between dilutions succuss (i.e. HIT) the remedy upon a firm yet giving surface – for example (and I shit you not on this one) a bible, a saddle or a leather gloved hand.”

… I didn’t previously notice the quite sexy undertones of succussion.

And as this part of my post becomes as self-referential as a paranoid schizophrenic after an ounce of cannabis, here’s some evidence… and a video.

Referring specifically to homeopathy, the British House of Commons Science and Technology Committee has stated:

In the Committee’s view, homeopathy is a placebo treatment and the Government should have a policy on prescribing placebos. The Government is reluctant to address the appropriateness and ethics of prescribing placebos to patients, which usually relies on some degree of patient deception. Prescribing of placebos is not consistent with informed patient choice – which the Government claims is very important – as it means patients do not have all the information needed to make choice meaningful.

Beyond ethical issues and the integrity of the doctor-patient relationship, prescribing pure placebos is bad medicine. Their effect is unreliable and unpredictable and cannot form the sole basis of any treatment on the NHS.
Although this is not scientific evidence you can feel free to wade through the Cochrane Library to see all the negative meta-analyses for many different things, seen as I can’t be bothered citing them. Go on – get to it!

Cranio-Sacral Therapy (CST)

One of the many underlying principles of CST is that restriction of movement of the cranial sutures (where the skull bones meet) interfere with the normal flow of cerebrospinal fluid (the fluid that surrounds the brain and spinal cord) and cause disease. Now, since my experience in paediatrics primarily involves feeling incredibly awkward, I can’t give you the exact age when you should stop being able to manipulate a human cranium in any real way, but I can tell you that its pretty early on. Based upon my experience in the Emergency Department, movement of bones at the cranial sutures is a pretty bad idea. It can cause such symptoms as funny turns, not feeling quite right and missing parts of your brain.

Evidence that it doesn’t work for those that want extra reading here!

Crystal Therapy

Hippies + crystals… need I say more? There’s usually some sitar music playing in the back of a very smoky and funky-smelling room to accompany the nonsensical burble about “quantum vibrations man!”

That dude is relaxed!

I'm not sure if this is better or worse than having a penis drawn on your face as you sleep

Faith Healing

I’ll let The Amazing Randi explain this one:

Implausible Mechanism

Any SCAM with an implausible mechanism is one where there is some very small evidence for an effect, but the mechanism touted by the practitioners is so far removed from reality that any effect must be due to something else. Generally this area of SCAMs is usually surrounded by some very good publicity, which means it is quickly accepted.

Chiropractic

To semi-quote Wikipedia:

“D.D. Palmer founded chiropractic in the 1890s, and his son B.J. Palmer helped to expand it in the early 20th century. Traditional chiropractors or “straights”  believe in the vitalistic concept of Innate Intelligence. This concept states that all life contains innate (inborn) intelligence and that this force is responsible for the organization, maintenance and healing of the body. Philosophically , chiropractors believe that they remove the interference to the nervous system (by way of a spinal adjustment) and that when the spine is in correct alignment, Innate Intelligence can act, by way of the nervous system, to heal disease within the body… the majority (mixers), are more open to mainstream views and conventional medical techniques, such as exercise, massage, and ice therapy”

I do hope that you, dear reader, have come to the conclusion that the above ideas about how life and disease works does not fit in with our scientific understanding.

Also, chiropractic is an example of a profession that feels it has built up enough arrogance to label its practitioners fully qualified doctors after only four years at university!  What an utter shambles. Furthermore, they then decide that physiotherapy is also part of their remit – what utter twats. I must now point out my personal belief that physiotherapists are all magicians and are trained at Hogwarts, they’re awesome!

I’m going to give the whole of chiropractic one last chance; let’s see how they deal with something they should be able to manage – back pain anyone? To quote a 2010 Cochrane Review:

Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.”

Oh dear… so they can’t sort out problems located in the only area of a patient they can actually manipulate any better than say physiotherapy. What a shame. Physiotherapy is free on the NHS. Chiropractic costs £25-80 a session, I know which I’m going for.

Magnet therapy (and other silly bracelets)

Magnet therapy is based around the idea that a portable magnet’s magnetic fields can penetrate deep into the body and affect the approximately four grams of weakly diamagnetic iron in the blood. This is supposedly meant to cure many a disease. How do we know this doesn’t work? Magnetic Resonance Imaging would either rip you apart or heal all your ills depending on how your blood was affected by the magnets.

A quote from a BMJ article (BMJ 2006;332:4 – you will need a BMA login to read the full article)“Extraordinary claims demand extraordinary evidence. If there is any healing effect of magnets, it is apparently small since published research, both theoretical and experimental, is weighted heavily against any therapeutic benefit. Patients should be advised that magnet therapy has no proved benefits. If they insist on using a magnetic device they could be advised to buy the cheapest – this will at least alleviate the pain in their wallet.”

Similar to magnetic therapy, we also have Power Balance bands – who had a few problems with their scientific claims in their advertising, and are now not allowed to claim that their products work in any real way.

The following is a report from Australia in which a reporter fails to realise that if you stretch a muscle and hold the stretch, the next time you stretch it it should go a little bit further. I loves dem Golgi bodies!

And here’s how it’s all done:

Acupuncture/Acupressure

See my last post for more in-depth information. There’s some data there that’s not especially great, but worth a look if you’ve not already been there. So are the mechanisms of acupuncture and acupressure implausible? Well, the mechanism purports that Qi (life force) flows through Meridians (channels under the skin) which when blocked cause disease. Sticking needles in people or jabbing them with a finger somehow unblocks these. Meridians have not been identified as any anatomical structures and are completely undetectable, yet are very easy to both find and manipulate if you have training as a snake oil salesman.

Reflexology

Reflexology is based upon manipulating the hands, feet or ears with thumb or finger pressure, as each of these apparently has some kind of reflex homunculus which allows you to directly interact with that organ, and thereby cure disease related to said organ.

This is how your feet look to a reflexologist. I'm worried those toes need amputating

Now I didn’t bother to look up sources for reflexology not working because John C McLachlan (Professor of Medical Education at Durham’s Queen’s Campus – part of Newcastle University Medical School) has done the work for me. After receiving an invitation to submit papers to an International Conference on Integrative Medicine, he invented a ridiculous story about a new form of reflexology and acupuncture with points represented by a homunculus map on the buttocks. He claimed to have done studies showing that “responses are stronger and of more therapeutic value than those of auricular or conventional reflexology. In some cases, the map can be used for diagnostic purposes.” It was a hoax, but a hoax with a fantastic picture.

Do you really want some stranger manipulating your liver from here?!

The fact this man is working for my university makes me a little bit happier. It doesn’t explain why that same university’s approach to teaching on CAM has been so poor though.

Iridology

A similar idea to reflexology, but instead using someone’s iris to diagnose their health. The patterns, colours and other characteristics of the iris are used in conjunction with an iris chart, which once again (surprise surprise) is a homunculus.

Fire hot. Water wet. CAM stupid.

Here’s some of Edzard Ernst’s work on what the data says – it’s not looking good through my eyes (I don’t even think this counts as a pun it’s so poor).

Poor Quality Data for Efficacy

I love them data!

Prayer

I’m not getting into religion here. It’s not what this blog is about and I can’t be bothered having to deal with trolling from either side of the argument. Up front: I really don’t care what your religious beliefs are. I am an atheist because I can’t see any way to allow both critical thinking and religious doctrine to coexist within one human brain. Anyway, we’re here to talk about the treatment aren’t we?

This might be my favourite paper ever: seriously please at least read this abstract. In fact, my favourite part of this study is the bias that should be present in the study. Generally the funding of a paper leads to a bias in favour of the funders. This study was funded by The Templeton Foundation which is a funding organisation with a pro-religious bent. The fact that not only do we see no effect on outcomes, but a negative effect on complications for those who were prayed for, really says it all. Either the researchers were being perfectly open and honest about their research (which would make me a very happy chappy) or they might have had an even more damning set of data and their funding bias altered it somewhat. I am happy to believe that they just played it straight.

Here's some inspiration when you're next thinking WWJD

Probiotics

Probiotics are those lovely little yoghurt drinks that you can have in the morning. They have friendly bacteria in them which can enter your bowel and be merry whilst doing all manner of good for you. Now, there is a rationale for giving patients on ITU probiotics to avoid colonisation by Clostridium difficle, but I don’t think it needs covering here. If you have any questions about this please call your local neighbourhood Infectious Disease doc. They’ll fill you in.

Probiotics as most people will encounter them will be marketed with a few claims:

  1. Boosts your immune system – if you ever hear this please cry bullshit. There are a couple of ways your immune system can be boosted, but you have to be in a bad state to need these. One is antiretrovirals for HIV patients, the other is G-CSF in neutropenic (no immune response happening here!) patients following chemotherapy. If you want to have a boosted immune system as a healthy person, you’re getting an autoimmune disease.
  2. Enhanced general well being – wishy washy unquantifiable bullshit.
  3. Protects your DNA – by coating you in lead and protecting you from cosmic rays?

The European Food Safety Authority has so far rejected 260 claims on probiotics in Europe due to a lack of evidence. These include:

  • Lactobacillus paracasei LMG P 22043 does not decrease potentially pathogenic gastro-intestinal microorganisms or reduce gastro-intestinal discomfort.
  • Lactobacillus johnsonii BFE 6128 . Immunity and skin claims all too general for consideration under the NHCR.
  • Lactobacillus plantarum BFE 1685. Immunity claim deemed too general for NHCR.
  • Bifidobacterium longum BB536 does not improve bowel regularity; does not resist cedar pollen allergens; does not decrease pathogens.
  • Bifidobacterium animalis ssp. lactis Bb-12 does not help maintain normal LDL-blood cholesterol; does not decrease pathogens or boost immunity.
  • Lactobacillus plantarum 299v does not reduce flatulence and bloating or protect DNA, proteins and lipids from oxidative damage.
There’s still a lot of research going on into the use of probiotics for treatment, so I will withhold judgement for the time being. Just consider this: if a health improving product is being marketed directly to the consumer and not being given to everyone by their doctor, might there be a reason?

Vitamin super-supplementation

Vitamin C prevents the common cold. Vitamin D stops flu. Doesn’t that sound fantastic?

Megadosing of Vitamin C has never been conducted in large scale trials, as it seems fucking mental. Megadosing involves giving 10-100 times the recommended daily allowance of Vitamin C intravenously in an attempt to cure a whole load of conditions.

Normal amounts of Vitamin C for the common cold prevention has been shown to have no effect according to a 2010 Cochrane review.

Supplements or these bad boys. What's your excuse fatty?

I recently worked with an endocrinologist who was of the opinion that Vitamin D is a panacea. I don’t know if I agree with him, and research is still under way looking at supplementation, so watch this space.

Less Efficacious than Conventional Medicine

Efficacy is paramount, and when it comes to SCAM we in the medical profession love to steal the effective stuff and turn it into medicine. This unfortunately means that there are very few SCAMs left that are helpful.

Herbal Medicine

Ladies and gentlemen, I give you St. John’s Wort. It’s genuinely amazing. It’s a herbal remedy that works. They love it in Germany. Hell, even the Cochrane reviews say it works. To be more accurate, they say the following:

The available evidence suggests that the Hypericum extracts tested in the included trials a) are superior to placebo in patients with major depression; b) are similarly effective as standard antidepressants; and c) have fewer side-effects than standard antidepressants.
There are two issues that complicate the interpretation of our findings:
1) While the influence of precision on study results in placebo-controlled trials is less pronounced in this updated version of our review compared to the previous version (Linde 2005a), results from more precise trials still show smaller effects over placebo than less precise trials.
2) Results from German-language countries are considerably more favourable for hypericum than trials from other countries.

So, once again we are presented with the eternal problem of Cochrane reviews: piling up many cow pats does not somehow make a bar of gold appear from the resulting pile.

There are also a couple of side effects to discuss:

  1. Drug interactions with: antiretrovirals, digoxin, methadone, omeprazole, phenobarbital, theophylline, warfarin, levodopa, buprenorphine, irinotecan, beta-blockers, calcium channel blockers, benzodiazepines, hormonal contraceptives, antiarrhythmics, statins and immunosupressants. To give an example or two. (1)
  2. St John’s wort has been shown to cause multiple drug interactions through induction of the cytochrome P450 enzyme CYP3A4, but also CYP2C9. This results in the increased metabolism of those drugs, resulting in decreased concentration and clinical effect. I’m just throwing this out there but that’s probably not the best idea for people whose livers need to be working well should they (for example) overdose on paracetamol. Damn my pragmatism!
  3. Rarely causing photosensitivity and cataracts
  4. Then there’s “associated with aggravating psychosis in schizophrenia”(2) – probably not the wisest choice in the mental health population as a whole.
I’d rather go with the anti-depressents, which according to the Cochrane review have a worse side effect profile, but I’d at least be able to take my other mind controlling drugs with them.

Fringe Ideas/ Not Accepted as Useful (by the scientific community)

Naturopathy

Naturopathy is natural medicine, and relies upon the naturalistic fallacy (which when said out loud sounds a lot more exciting than it is). The naturalistic fallacy states that: it is natural = it is good. Obviously, there’s a reason it’s a fallacy and here are a few: arsenic, mercury, polio, puberty, and Celine Dion – all natural and all absolutely awful. Naturopathy is practised primarily by middle class Westerners and a few small tribes in South America and Africa. Guess which one practices it out of necessity, and therefore is far stricter with its practices. Guess which one has a lower life expectancy. Now I know correlation is not causation, but I highly doubt that the reason naturopathy hasn’t been accepted into the mainstream is due to a Big Pharma Conspiracy. Then I would say that with all the money they give me…

Summing up

Hopefully this has been enlightening, and you may be a little better equipped to deal with the beliefs patients may hold about SCAMs. If you disagree with anything above, that is fine.

““That which can be asserted without evidence, can be dismissed without evidence.”  – Christopher Hitchens

Here’s some funnies:

Housekeeping

Well done if you got all the way to the end!

Don’t be a twat.

References which I couldn’t link to :

(1) Rossi S (Ed.) (2005). Australian Medicines Handbook 2005. Adelaide: Australian Medicines Handbook. ISBN 0-9578521-9-3.

(2) Singh, Simon and Edzard Ernst (2008). Trick or Treatment: The Undeniable Facts About Alternative Medicine. W. W. Norton & Company. p. 218. ISBN 978-0-393-33778-5.

14/01/2012 / Pedanto

Palliative Acupressure

It’s Happened Again!

Once again I am faced with a day of palliative care teaching. Woe is me!

Yes, palliative care is nice (well the care providers are at least), and I’ve seen some great work from palliative care teams. Hospices somehow manage not to be as depressing as they should be – which is surely a testament to the skills of the those running them. I might even consider a career as a palliative care physician were it not for the following reasons:

  1.  The slightly odd view on evidence they hold
  2.  I have a serious problem being even slightly sensitive (I bet you hadn’t even noticed!)

Learning is Fun

So here we are sat in a group of about twenty students, a doctor, and a nurse. We are excited to receive teaching on anti-emetics (sickeningly fun!) and the Liverpool Integrated Care Pathway (why did they put in the word integrated? It just reminds me of Prince Charles’ forays into medicine!). – and yet another link on that subject 

The discussion begins with a little bit on the physiological basis of vomiting. Fairly useful for those of us who work things out from first principles (I have serious issues remembering anything in any other way – probably not the best attribute in that kind of person who needs to remember all that medical stuff…what are they called again?). Then we move onto anti-emetics. First it’s non-pharmacological approaches.

Pain and Pressure

We are invited to jam our thumbnails into a spot between the tendons on the underside of our wrists. Manipulation of this specific acupressure point is apparently good for decreasing nausea and vomiting. Strangely it made me feel a bit sick – perhaps it’s a little homeopathic with its law of similars.

Back to the learning – “What is acupressure?” I hear you cry.

Recap and Reflect

Remember what I said about acupuncture?

“Meridians and all that stuff. Here’s a quick explanation about Qi and Meridians: a long long time ago in China autopsies weren’t allowed. Therefore anatomy had to be invented. Some very fanciful people made up magic life force and channels they pass through. Then like my toilet after a kebab, that shit stuck.

Apparently sterile needles are used – I personally wouldn’t trust the autoclave of someone who thinks that shoving pins into you will help anything.” – addendum: I have never seen a picture of an acupuncturist using gloves.

She looks very cheery for someone who’s just been given Hepatitis B

.

Acupressure’s like that; but without needles. This gives it some serious advantages:

  1. It will not cause serious infections due to the lack of understanding of germ theory and aseptic technique by practitioners.
  2. It should really cost less.
  3. It appears to be even more magical than acupuncture (Healing Hands is a fairly advanced spell as far as I’m aware….then again I never level up Restoration).

Once again I’m very aware that my medical degree has not had much emphasis on the minor things like science, reason or how the world actually works. In fact for a science-based degree there appears to have been very little assessment of whether something is believeable. The following phrases are seemingly unknown by the majority of Newcastle graduates: confirmation bias, cognitive dissonance, the file draw effect. Instead we are taught to unerringly elicit and respect patients’ “Ideas Concerns and Expectations” without any capacity to challenge them if they are either repulsive or stupid, as apparently the most vital part of making a patient better is their fondness for you – for more information see here.

Tangential Tangents Aside

Anyhooo to the matter at hand. Where does one look for answers to life’s big questions? How about this guy:

Nothing gets me going like some good Data

.

Acupuncture for nausea and vomiting in palliative patients. Let’s find some literature. Here’s a Cochrane review, once again not my favourite type of literature as, to quote Mark Crislip, “If you make a huge pile of cow pats don’t be surprised when it doesn’t metamorphosise into gold“. But hell, I can use some cognitive dissonance to make this whole thing fit my viewpoint – which it does! God bless confirmation bias! (see what I did there – apparently call-backs work really well in stand-up… which now I think about it this is almost nothing like… shit!)

To quote:

Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting

Ezzo J, Richardson MA, Vickers A, Allen C, Dibble S, Issell BF, Lao L, Pearl M, Ramirez G, Roscoe JA, Shen J, Shivnan JC, Streitberger K, Treish I, Zhang G
Published Online: 
March 16, 2011 (THIS SHIT IS UP TO DATE!)

This review looked at whether stimulating acupuncture points could reduce nausea and vomiting caused by chemotherapy. Acupuncture points can be stimulated (Does this imply that they exist?!) by acupuncture applied with electricity (electroacupuncture), acupuncture without electricity (manual acupuncture), acupressure (pressing on the points usually with fingertip), or electrical stimulation on the skin surface such as wristwatch-like devices. Electroacupuncture reduced first-day vomiting, but manual acupuncture did not. Acupressure reduced first-day nausea, but was not effective on later days. Acupressure showed no benefit for vomiting. Electrical stimulation on the skin showed no benefit. All trials also gave anti-vomiting drugs, but the drugs used in the electroacupuncture trials were not the most modern drugs, so it is not known if electroacupuncture adds anything to modern drugs. Trials of electroacupuncture with modern drugs are needed.

And furthermore:

Self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients, though studies did not involve placebo control.

Interpreting Cow Muck

Wait a second though – doesn’t that mean that acupressure has a benefit for these patients?

Not really. Firstly, without a placebo we can’t see how it might have compared to giving them  “Thewlisco Unicorn Kisses – the purest snake oil money can buy”. In fact, all it shows us is that if you tell a patient something will decrease their nausea, it appears that it might – as long as you do it in advance. A suitable placebo for a trail could be a random point being pressed which had not previously been linked to nausea and vomiting, whilst the patient was told it would help their symptoms – it’s amazing it wasn’t used, but then that might have confounded the magical world view of many CAM practitioners.

So when we were informed that “this reduces nausea”, to quote Ben Goldacre “I think you’ll find it’s a bit more complicated than that”. (officially the sexiest catchphrase ever)

The Message

Once again, what’s my point? Should palliative care teams get rid of their placebos? Probably not, they really have nothing to lose (well apart from paying for the services of wizards). If it makes a dying patient feel a little better then damn the evidence.

Once again my problem is with Newcastle University Medical School. I’ve recently been fobbed off by them on a rather important matter, so perhaps some of my less than amorous feelings are creeping in here. It seems like our training has been geared towards creating 350 incredulous GPs who are really good at hugging patients, but who come out of higher education as scientifically illiterate useless drones who might have a heart attack when attempting to open a copy of the New England Journal of Medicine. Even worse there will be some amongst us who are willing to propagate bullshit because they lack the inclination to be critical and pedantic.

On one final note: you are taught to be open and honest with patients. You are taught to ask about their ideas, concerns and expectations. You are asked to understand their health beliefs. You are asked to respect these (I will respect their right to hold them, but not their specific beliefs). You are told that a placebo is useful. Does anyone else feel uncomfortable directly lying to patients? Isn’t that in some way bad?!

Here’s your funnies:

Don’t be a twat

22/12/2011 / Pedanto

The Food Hospital – or “Eating for Dummies”

Having returned home for the Christmas holiday I found myself on Tuesday night sat in front of the TV waiting for Jamie Oliver’s usual turkey oriented food program. What a pleasant chap Jamie is.  Unfortunately the hour prior to this I was forced (yes forced!) to watch the  following program.

Hoho! An apple a day keeps the (science based) doctor (who doesn't want to just sell you snake oil) away.

I have made a point of avoiding this program as all it was likely to do was fill me with impotent rage. In fact it filled me with righteous indignation, which is what happens to impotent rage after half a bottle of wine. This irresponsible and worthless piece of infotainment was lacking even an iota of sincere critical analysis.

The Premise

Tagline: Using Food as Medicine.

Now I thought medicine was medicine – isn’t food something different?

Case Study

47-year-old overweight woman with a fairly poor diet.

Now to all the people who want to play the diagnosis game you can have a clue about which particular problem she is likely to have. I’ll give you a clue it ends with “-iabetes”. This however was not on her list of major concerns, her main worry was cholesterol which she claimed to know little about apart from that it was bad for you.

We then got an explanation of what cholesterol is, and what it might do to you. The important thing to remember with imparting science to the public is that often their pre-existing level of scientific understanding can be so minimal that simplification is the order of the day. In fact due to the level of literacy in the North East of England medical pamphlets are written for a reading age of around 11 years old. There is one major problem with simplification of complex ideas; when explaining complex physiological processes to the general public one often appears to be a condescending twat.

 The bright colours were my favourite bit

After the initial home shot segment on the patient’s concerns there was a consultation with a man who I can only assume was a doctor because he was wearing a stethoscope.

I genuinely believe that the communication skills teaching we get in medical school is useful – enough of use are socially awkward troglodytes that learning to speak to patients in a formulaic manner is probably a useful exercise. Standing over the patient whilst she is laid on an examination couch to explain the results of blood tests it became clear this young doctor never attended his communication skills seminars.

Anyhoo – all her blood test results are discussed. Cholesterol is high (hint: if you’re a tubster you’ve probably got high cholesterol). Glucose is 6.8 on a random test – that’s hovering around diabetes country and what is the suggested follow-up for that? I’ll just leaf through my home printed copy of the NICE guidelines on diabetes.

I spend a lot on printer ink.

*******************************

7 and a half hours later

Ah ha! It’s time to test this lady with a glucose tolerance test.

I do hope this responsible doctor did just that.

Oh dear he didn’t!

Instead he prescribed her a diet rich in soy milk, tofu and not eating KFC. All seems sensible and without the use of those oh so expensive drugs. After all spending £30 a week more on food must be much easier and cheaper than taking a Simvastatin tablet (other statins are available) for £1.50 a month. I know this woman was a blob and needed to lose weight but at no point did anyone suggest exercise. Get her on Fitocracy and see the weight drop away.

When she was followed up a month later her cholesterol was lower and with the magic of inappropriate testing her blood glucose was lower as well. 2 random blood glucose tests a month apart is my new therapy for patients with impaired glucose tolerance.

Case Study

Female patient (20’s – I could have re-watched this on 4OD to check her age, but I can’t bring myself to knock my IQ down by another couple of points) with PMS. She had been prescribed low dose SSRIs (selective serotonin re-uptake inhibitors – antidepressants) by her GP to help control it. She had however decided not to take these as she wished to control what chemicals went into her body. Perfectly reasonable as long as you plan on living like this:

Dress sense this good can only come about from controlling all the chemicals that go into your body

To quote the young lady in question: “I’ve tried everything”. I’m sure that the words “apart from the prescription from my doctor which could have helped” was just edited out to make her look stupid.

Her prescription was a dietary increase in carbohydrates to boost her serotonin; now I can’t help but wonder if a selective serotonin re-uptake inhibitor could have helped with that kind of thing. But then again I would suggest that for my Big Pharma cheque.

So here’s her gynae history  (turn away now if you’re squeamish) :

Dr: “So where in your cycle are you?”
Patient: “I’ve just started on my period.”
Dr: “Grim!”
Patient: “Yeh! I know.”

So after six weeks she was brought back in for follow-up to discuss her current lack of PMS. What a surprise. Phil Plait once said “I predict that there will be an earthquake two weeks after either a full or new moon” – just saying!

Case Study

Raw food vegan worried about being deficient in Vitamin B12 who supplements his Vitamin B12.

Moron.

Public Information

Ironically they even have little critical thinking pieces such as the one below in the program, swiftly followed by bullshit.

Clinical Research

Here’s my real issue with the Food Hospital. I honestly don’t care if fat people want to get thin in a way that seems easy, or if hippies want to eat naturally whilst heavily supplementing their diet with multivitamins made in huge industrial complexes. If you choose to be an idiot that’s fine with me.

It’s the apparent research which is being conducted. Clinical trials for people who are worried about their health. Don’t worry there is an app for that.

The current clinical trials running from the Food Hospital. I wonder where they'll be published....

So how is this trial run? Direct from the website we have the following instructions:

“For 6 weeks, you will be asked to eat a small amount of either dark or white chocolate and answer 5 questions every day.You will also need to take 3 blood pressure readings (once at the start, middle and end of your trial).
To take part in a Food Trial, you need to sign in or register for a Channel4.com account. You will be asked to do this on the next screen.”
 

So to assess the data that will be collected. Self selected patients who are worried enough about their health to be self enrolling on a clinical trial who will have the following things in common:

1. They watch The Food Hospital.

2……….

Thought I had a second point there but apparently not. The bias leaking in already is astonishing. Any statistician who can look at the data that will be collected here and draw any sort of meaningful conclusion quite frankly could beat Stephen Hawking in an intellectual pissing contest.

Each patient is then self reporting 3 objective values over 6 weeks which will be invariably taken on different machines at different times of day  and probably in different positions. For the sample size to offset the error produced from this we’d probably require the entire UK population to take part.

Now the results which were published and peer-reviewed on prime time Channel 4 were as follows: Dark chocolate eaters had an average drop of less than 3mmHg of blood pressure. White chocolate eaters had an average drop of only 0.1mmHg.

Can you say error?

I’m signed up to do clinical trials as a lab rat for a certain company which generously compensates its participants. I am also aware that they won’t accept you for a trial if you’re even slightly outside the realms of normality with any of your demographics or physiology. A slight ECG change will deny you £1400 for a weeks work. Them’s some tight controls! The Food Hospital’s producers really should have read up on conducting a clinical trial prior to starting one.

I can quite easily eat a hand towel and then examine the resulting faeces and sweetcorn imbued rag and gain more useful clinical data than this trial. Actually it probably wouldn’t be that easy as Jack just showed me.

The Message

I understand the point of The Food Hospital is an attempt to get people living slightly healthier lives, making them engage with science and allowing them to take command of their own health.

I’m all for that.

If everyone was healthier, scientifically literate and could look after their own health completely I would happily retire to somewhere incredibly warm to drink rum out of coconuts. I would subsequently go into liver failure and wish that I’d eaten more almonds to detox my liver.

Unfortunately the program either innocently missed the mark or has been hijacked by another agenda somewhere along the line. I know where I’d put my bets.

TV attempting to explain science and health with pseudoscience and wellness is not helping anybody. It will make the worried well part with too much money to supplement their diets with all natural detritus, and it may make the truly ill delay seeking real medical advice in an attempt to heal themselves naturally.

Here’s your Christmas funnies:

Here’s my hints on how to live a healthy life:

  1. Get off your arse and do some exercise. If you are a gamer then why not try Fitocracy. You can level up by doing pressups!
  2. When you can see the fat dripping off something perhaps think twice about eating loads of it.
  3. Enjoy your food.
  4. Drink to excess only when you really want to.
  5. Try not to do things that you know are bad for you. If you fail – hell you’ve only got one life, enjoy it!
  6. Don’t be a twat.
01/12/2011 / Pedanto

Education Misinformation

As we sit in a lecture theatre after a morning of palliative care (teaching not treatment) the lecture I’ve been waiting for has finally arrived. I’ve been building up my bile stores for days. I’m ready to kick some arse. Finally some teaching on complementary and alternative medicine.

When I last had teaching on CAM I was uniformed about it. The only thing I would have been able to do would be to cry “BULLSHIT!!”. I hardly knew anything about CAM. James Randi, Edzard Ersnt, Ben Goldacre, Simon Singh, Mark Crislip, Brain Dunning, the SGU rogues and the podcasting members of the Merseyside Skeptics Society; all these were complete unknowns to me. My inner skeptic was barely embryonic by this point. I simply sat there impotent and unable to debate. How does one cry bullshit without the evidence? Of course just drawing on an understanding of science helps, however without evidence I could never have combated the special pleading and magical thinking that CAM promoters put forward. Simply to have denied someone’s claims without any evidence to refute them would have made me look like a tosser. Go figure!

Nemesis

But here I am on the first of December 2011 ready to take this bitch down. I was hoping for a Lex Luthor to walk through the door, instead I’m presented with someone’s grandma.

Bollocks!

Surely I can’t be a cruel bastard to this harmless looking dear. Hell, she works for Marie Curie Cancer Care, a charity which seems pretty pleasant really.

Then out come these words: “Hello I’m **** **** from Marie Curie Cancer Care. I’m a registered nurse and a certified reiki practitioner”.

Fuck this bitch.

My Fellows

I am very aware that I probably have an unusually high level of understanding of what complementary medicine entails amongst medical students. I don’t say this to sound superior, but it is true. Generally we as a profession are aware that most CAM is abject bullshit, however not many of us have put aside the time to find out about it in more detail. Perhaps the fact that I have points to some kind of underlying personality disorder….

Sure baby I can prescribe whatever I like!

Anyway back to my point. We generally don’t know much about CAM and this lecture was meant to be educational. So what was covered?

Massage

I have no problems with massage. It seems nice and helps with palliation. All in all it’s good. Claiming it’s 3,000 years old as our lecturer did riled me a little as there was no back up for this claim. But hell I’m an easy going kind of guy, and she only had 15 minutes so I’ll let that one pass.

Aromatherapy

We got hit straight between the eyes with an implied naturalistic fallacy (it’s from plants which is in some way good). There wasn’t really much more content to this section apart from the warning us that some of the oils can be “very strong”. I not long ago ingested some naturally occuring by-products of fungal metabolism and because they were “very strong” I felt a little peaky and had to empty my guts neatly in an Armitage Shanks sanitation device. Just to be clear “very strong” seems to be a synonym for toxic. Here’s your resource for further reading (there will be a test).

Reflexology

Now we’ve hit woo town! So my foot is a homunculous of my body apparently. Oh and it dates back to ancient Egypt does it? Now they were known for their amazing scientific advances in healthcare – their hook based neurosurgery never seemed to take off though. Fortunately we did have a walking talking data point telling us she could feel each individual organ as it was being stimulated by the reflexologist. That’s the word I’m looking for right? Right?

Oh shit I remember!

DATA = PLURAL

DATUM = SINGULAR

ANECDOTE = AN EFFECTIVE WAY OF CONVEYING A LIE

Finally she revealed that she’d never stayed awake through an entire session of reflexology – perhaps indicating if nothing else it may be good for insomnia.

Reiki

Magically waving your hands over someone’s body. Right, that’s useful. Apparently the patients she treats have many reactions to this, many of which sounded like hallucinations. Now I’d never accuse a well meaning hippy of doping someone. But if I were a well meaning hippy I would definitely dope someone. Just to reinforce, I’d never accuse a well meaning hippy of doping someone. But if I were a well meaning hippy…..

Acupuncture

Meridians and all that stuff. Here’s a quick explanation about Qi and Meridians: a long long time ago in China autopsies weren’t allowed. Therefore anatomy had to be invented. Some very fanciful people made up magic life force and channels they pass through. Then like my toilet after a kebab, that shit stuck.

Apparently sterile needles are used – I personally wouldn’t trust the autoclave of someone who thinks that shoving pins into you will help anything.

Hypnotherapy

By this point I had burst 3 of my berry aneurysms, but I’m a trooper so I kept listening. Fortunately this was all fine – balancing mind, body and spirits using pieces of something I think. All fairly nebulous crap. There was a mention of using it to treat PTSD – not very happy with that idea myself as I can’t find any evidence to support it’s use apart from the very occasional case study.

Health and Safety

We then got a little talk on the safety protocols that are in place to protect patients these included:

  1. An information leaflet about therapies which I’m sure will both make the general public scientifically literate and give them fantastic critical faculties.
  2. Written consent is required – usually only done for unwise decisions such a allowing a surgeon to cut you open or someone to stick needles in you.
  3. Therapists are all certified by a respectable organisation. And I’m sure the fact that I have a bit of paper saying I can perform a wedding in America really does give me that power. Plus I’m a nutritionist don’t you know!
  4. They maintain confidentiality – woop de fucking doo! I hope this doesn’t catch on with other health professionals.

Evidence

Finally we got a little insight into some special pleading. She began by saying that research was difficult, as taking the therapist out of the equation would bias it in some way. Well that’s what we in the biz (nutritionists like me) call a “lie”. There’s plenty of research out there, both good and bad, positive and negative. Strangely the negative stuff seems to be the good and the positive stuff seems to be the bad. How odd.

Where’s My Beef?

So what’s my point? I’m sure none of my colleagues were taken in by the magic we were told about (though people should get into magic more. It’s really cool!!!).

Shortly after the lecture, in the canteen I had to give a little teaching session of my own. Some people saw no harm in CAM as they had only seen helpful masseuses in hospices and hadn’t encountered the likes of Jim Humble or Mathias Rath.

Some people felt that more research needed to be done and that no funding was available for this –  a simple lack of knowledge is on show here that a quick look on PubMed would solve quickly. There’s a lot of evidence out there, it’s just the people who promote CAM wish to ignore the evidence which puts it in a bad light. And once you’ve cherry picked away all the evidence disagreeing with magic you are obviously left without much, and it’s understandable to want more research on this area because there’s so little!

I don’t have a problem with CAM in end of life care. Why not have a massage? It could be very nice. I fondly remember my own grandad receiving some fantastic complementary therapy in a hospice in the form of some Guinness my Dad bought in – it wasn’t medicine, I’m fairly certain there’s no evidence for it, but it cheered him up.

So here’s my message: CAM teaching at medical school in the UK is poor. Very poor. It allows a believer a platform to drool out their nonsense. Without any input from a scientist or your friendly neighbourhood skeptic. If tomorrow’s doctors are expected to deal with patients’ health beliefs and preferences, an awareness of what they actually entail might be useful. Even more importantly we are scientists first and foremost, and allowing some of us to walk out of a science degree believing in health based fairy tales is irresponsible.

Thanks for reading.

Here’s your funnies:

Not quite as skeptical as usual but it’s probably worth relaxing sometimes.

Housekeeping:

  1. Sorry for the unusual amount of swears this post. It’s been a while since I last wrote and for some reason the ability to articulate myself without being crude has disappeared. I will try to be more genteel next time.
  2. If you go to a medical school beyond Newcastle (surely you can’t survive in such warmth all year round!) I’d be very interested in hearing if your CAM teaching has been any better.
  3. Don’t be a twat.
08/10/2011 / Pedanto

Appealing to My Own Authority

I have recently been dragged into a few arguments with people on the internet, and just like the angry thirteen year old I have decided to become, I thought it best to justify my position in front of the whole world. Now I know that simply saying “I’m almost a Doctor” is a pretty obvious logical fallacy in the form of an appeal to authority, so let me justify myself.

My revision for finals had taken a rather unexpected turn

 Where I’m wrong

I do not claim to be right all the time, in fact I’m happy to learn from my mistakes. I hope to approach all the debates I go into with an open mind, ready to receive some new information which will make me change my mind. I, like everyone else, am prone to confirming my own biases, not questioning information which agrees with my prejudice and doing some fantastic backflips of cognitive dissonance when I am quite obviously wrong. Hell I like to continue arguing even when I’ve realised that my opponent is right (more often in a face to face argument) because I’m a bit of a contrarian twat. Probably not the easiest thing for a lot of people to live with.
For this I now send out an eternal apology to everyone I might offend in the future by needlessly bating them.
Right now that that’s covered back to why I am right all the time (at least on the internet).

Where I’m right

It’s always nice that people will believe bullshit they read on the internet and assume that doctors have no idea about science.
Here’s an example from my old stomping ground. That article essentially tells the dear reader some absolute bullshit about how vibrations in water molecules hold the memory of whatever has been in it. That’s fine, it’s from www.naturalnews.com and it’s nothing less than I’d expect from them. No real references, no papers, not a single proper name drop of anyone with a little bit of credibility that might agree with the author. Fine. I don’t care – that is what natural news is about. As I’ve previously touched on, natural news, like many pseudo-scientific naturopathic websites out there, are primarily well designed store fronts for Big CAM. They will be making plenty of profit from the shit they’re selling. Ben Goldacre has refered to this as “a self administered tax on the scientifically illiterate” and I’m growing more inclined to agree. So here it is. If you’ve read all the evidence (or even a respectable summary of the evidence with as little bias as possible in it) and you’re happy to disagree with me – go ahead. You’ll be wrong, but I will bear you no ill will. The problem is if you haven’t spent the  three minutes required on Google to form an opinion based upon anything more than what the nice man who raps and sells you vitamin D says, then please don’t start to argue with me. Even worse, don’t use my education as a point against me.

A little about me


So here’s where I stand with my understanding of science. Two years of sixth form concentrating on the sciences followed by five years of a medical degree.

Just a quick aside: for any prospective medical students out there that half-arsed pretentious nonsense about medicine being both a science and an art is absolute humbug! Humbug I say! It’s a science practised (in general) by people with enough social competence to allow them to explain very complex ideas to the very stupid and poorly educated. To be clear I am not calling all patients stupid. I am calling SOME patients stupid, as inevitably some people who get ill fall at certain points on certain bell curves and that inevitably leads me to meet some stupid people. I also meet some extremely clever people who leave my intellect in the dust.

If we decide to count GCSEs, that comes to almost ten years of my life spent gaining a measurable competence in understanding science. I also like reading about science, but only the really cool stuff that really confuses that gaping existential vacuum within me. I have not conducted any real (i.e. published and peer-reviewed) research first hand, but being the pedantic skeptic I am I have familiarised myself with the methods of research quite thoroughly. I may not be an authority on any given subject but I most certainly am able to comment on whether an assertion is unsupported or whether the wrong conclusions have been drawn from a paper.

This opinion does not wash with anyone who I happen to argue with on the internet about pseudoscientific nonsense. Apparently having such a strong faith in the sciences means that I do not have the ability to objectively step back from the views of mainstream science and accept what I’m being told by someone who considers having a child with ADHD a qualification.

Oh wait.

No…

That’s complete and utter bollocks.

I would like to state categorically that no true scientist (name that logical fallacy!) would be happy to say they have faith in anything. It runs against the ethos of science to place faith in a particular idea, as someone might well turn around tomorrow and tell you that they’ve discovered neutrinos going faster than light speed. Then where would we be had we raised Einstein to the status of an infallible god? We question, we hypothesise and then we test. If the hypothesis doesn’t stand up to the testing then we go back to questioning.

I will readily admit that I have a bias towards provable scientific theory, I have spent a lot of my life using it. Sticking to the floor and that! However if tomorrow someone can show me some good evidence that the crap CAM pushers peddle is anything more than a very effective cash cow I will (to quote time Minchin) “carve it on the side of my fucking cock!”

In Summary

I stand here with three hundred years of the enlightenment at my back, thousands of points of data supporting my views, and with the brightest minds of all time on my side. I am most certainly standing on the shoulders of giants, not sitting around thinking that life is too confusing to actually put in the effort to actually find out what the fuck is going on.

Life is big, scary and difficult and that’s what makes it so wondrously, blindingly brilliant.

Here’s the funnies:

Housekeeping:

  1. Sign up to the Anthony Nolan Trust if you haven’t. If you want to show how much of a man you are try to beat my donation of 5.6 units of bone marrow to someone who needs it. If you don’t want to show how much of a man you are (for example if you are a woman) then it’s worth signing up to because you could really help someone who needs it, and you get some pretty sweet freebies for donating.
  2. Don’t be a twat.
27/08/2011 / Pedanto

Edzard Ernst Makes My Legs Turn to Jelly

If you don’t know this sexy man you soon should

A quick wikipedia summary:

Edzard Ernst (January 30, 1948 in Wiesbaden, Germany) is the first Professor of Complementary Medicine in the world, at the University of Exeter, England.

In 1993, Ernst left his chair in Physical Medicine and Rehabilitation (PMR) at the University of Vienna to set up the department of Complementary Medicine at the University of Exeter. He became director of complementary medicine of the Peninsula Medical School (PMS) in 2002. He was the first occupant of the Laing chair in Complementary Medicine, retiring in 2011. He was born and trained in Germany — Ernst began his medical career at a homeopathic hospital in Munich

He likes to put a smack down on people who sell bullshit

At the sound of a quack he leaps into action with a grin and a slap

Being the contrarian that I am I went looking for people who don’t like him as much as me and I found them.

The alliance for Natural Health Europe attempt to discredit him below. They even have a picture of him without his moustache.

http://www.anh-europe.org/news/edzard-ernst-on-the-self-promotion-trail

Is misunderstanding of science wilful?

To sumarise this article:

  1. Ernst says there is “no efficacy for homeopathy” and also says “homeopathy works…maybe as a very strong placebo effect”. This doesn’t explain why homeopathy works on animals
  2. Edzard Ernst used to work in a homeopathic hospital and has changed his views
  3. he and his colleagues rejected 99.8% of the available evidence on herbal medicine and concluded that “there is no convincing evidence that it is effective in any indication” (not true – try reading Trick or Treatment)
  4. A question on methodology which is must reproduce verbatim here so I may pick it apart:

“As we have pointed out before, the reason why Ernst’s assessments of natural healthcare are often negative is not simply that these healing techniques shrivel under the harsh light of scientific scrutiny.  Ernst’s methods, which we see applied in the same manner over and over to many different forms of natural healthcare, involve selecting what he deems to be high-quality studies and performing meta-analyses or systematic reviews on them.  Studies of studies, in other words. 

The problem comes when trying to separate out the ‘specific therapeutic effect’ from the plethora of related phenomena that must also be considered, and which together make up the ‘total therapeutic effect’ (see Figure 1).

Figure 1. Variables operative during clinical trials that contribute to the ‘total therapeutic effect’  NOTE: WHAT THE FUCK ARE THE UNITS ON THE Y AXIS SUPPOSED TO BE?

The RCT can only separate out the specific therapeutic effect from the total effect if all of the other phenomena in the Figure 1 are independent of each other, and operate the same under experimental and real-life conditions.  But just think of the practitioner–patient relationship for a moment.  As we said in our earlier piece, “Crucially, the bio-physical-energetic interactions between practitioner and patient, as well as internal neurophysiological and metabolic processes, are likely to be very different in these two contrasting circumstances…it is perhaps no wonder that Ernst finds that treatment effects are so often lost in the overall noise of the experiment – falling foul to the netherworld of statistical insignificance.”

We submit that it is no coincidence that many of Ernst’s studies have been negative.”

My response will probably be forever unpublished so please see it here in all its glory

This will probably never make the article's comments board

I also went on  to say that even if it is true that Ernst has ignored 99.8% of the available studies on natural health that doesn’t mean his point is invalid. In fact a rigorous view of research is required to make valid conclusions. Ernst probably did not take into account this 99.8% (does anyone else feel that this is too high a number? He would have literally looked at one trial, and man cannot make meta-analyses by one trial alone) for a variety of reasons

  1. It was anecdote (often accidentally pluralised to data amongst the naturalistic community)
  2. It was not performed on a large sample, controlled for or randomised
  3. It was written by pillocks who were attempting to confirm their own biases.

I’m sorry for putting this up as a post but my comment would have never seen the light of day had I not. I am enough of a narcissist to think the world would be poorer because of that.

Please sponsor me for the Great North Run for MacMillan Cancer Support at http://www.justgiving.com/David-Thewlis. It’s a good cause and my legs hurt.
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