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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.

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One Comment

Leave a Comment
  1. laurajaynewatson / Feb 14 2012 20:50

    Reblogged this on For Emergency Use Only. and commented:
    Extremely important reading for all of you folks who will have to strive against this crap for most of your careers (especially if you become a GP)

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