Mar 24 2008

Responding to Dana Ullman

Recently homeopath Dana Ullman has been gracing the comments section of this blog. I always welcome contrary views – it sparks great debate and always seems to deepen my understanding of what advocates are saying on all sides of an issue. Recently he has brought up some points that could use a detailed response, sufficient to fill a separate blog entry, so here it is.

In response to my blog entry on A Golden Age of Quackery and Antiscience, Dana Ullman wrote:

Quackery is commonly defined as the use of unproven methods by practitioners who claim impressive results and who charge a lot of money. When you consider how much of conventional medicine is not evidence-based, and when you consider how much they wear the guise of “science” and how much they charge for their services (and drugs), we ARE living in the golden age of quackery…conventional medical quackery.

This is a common reply by advocates of one or more unscientific medical modalities – the claim that mainstream medicine is also not sufficiently scientific. This usually is presented as a tu quoque logical fallacy – which means “you too” and is the counter of a legitimate criticism with the claim that others (often the accuser) also suffers the same vice. This is irrelevant to the validity of the criticism.

But that aside, let’s examine what Dana Ullman is saying – that modern medicine actually represents a golden age of medical quackery. This is absurd on its face. Medicine over the last several hundred years has been under constant evolution toward a greater founding in science and evidence. Medicine is more scientific and evidence-based now than it has ever been.

It is difficult to estimate the degree to which mainstream medicine is science-based, because this is not a black-and-white issue, but credible estimates are that 78% of what physicians do has a solid grounding in science and evidence (which is much more than the bogus figure of 15% often cited by CAM proponents). I discuss this question in more detail here.

I also think we can (and will) do better than this, because mainstream medicine is based upon a scientific standard of care. Evaluating treatments and diagnostic modalities are built into the system. Medicine is self-critical, as any science should be. Another strength of the system is that there are different specialties. So, for example, the surgeons that perform a procedure may be largely dependent upon referral from a non-surgical specialist who treats the same problems with different modalities. This provides an important cross-check to the system. There are also academics who typically do not make their money from practicing medicine and whose job it is to question and improve the current science and standard of care.

My overall impression (admittedly from the perspective of an academic) is that while there are many specific criticisms one could make, the overall system works and is heavily science-based.

The biggest problem facing the scientific basis of modern medicine today are those who are trying to promote so-called “alternative” modalities that are not science-based. In so doing they are trying to redefine what is science, or to change the rules of scientific medicine to allow for patent nonsense, or to eliminate the science-based standard of care so that anything goes.

It is also critical to point out that while we are talking about the scientific basis of treatments in mainstream medicine, we are generally referring to treatments that are reasonable and make sense when considered in the context of our scientific knowledge of biology. But we also recognize that this is insufficient to conclude that a treatment works, so we also demand high quality clinical evidence of safety and efficacy, but sometimes we need to make treatment decisions when definitive clinical evidence just doesn’t exist. CAM proponents will then compare this situation to theirs, in which they are advocating (as Dana Ullman does) for a treatment modality (in his case homeopathy) that has no scientific plausibility in the first place – not chemical, physical, or biological. The image of splinters and beams come to mind.

Dana Ullman specifically address surgery when he writes:

And don’t forgot those surgeons…as much as I respect their work, let’s not fool ourselves into thinking that it is based on double-blind placebo controlled trials. Oh, I see, this “gold standard” is not applicable to every medical treatment, nor is it or should it necessary be expected from every unconventional medical treatment either.

This is a straw man. I never claimed (nor, to may knowledge, has any serious commenter) that surgical interventions are studied with double-blind placebo controlled trials. This is simply not possible – for one because it is generally considered to be unethical to perform sham surgery; to tell a patient that you have operated on them when all you did was open them up, do nothing, and then close them back up.

What Dana Ullman is doing is implying that if you cannot do a placebo-controlled trial, then you are not scientific, and this is the same as using magic water as a treatment. However, placebo-controlled trials are not the only way to study a treatment. First, let us recognize that often surgeries are based upon a solid understanding of anatomy, physiology, and pathology. Surgery is often done to fix an obvious anatomical problem, or acute problems that have a well-known natural history.

Let us consider, for example, appendectomy. If an appendix becomes seriously infected in can become filled with puss and then eventually burst, spilling bacteria into the abdomen which will cause a widespread infection that is often fatal. Removing the appendix before it bursts is such an obvious intervention one must consider the ethics of withholding this intervention for a study. Also, we can compare outcomes from appendectomy to what we know historically about the natural history of untreated appendicitis. This is scientific evidence.

Surgical interventions can also be compared to best medical management – for example cardiac bypass vs anticholesterol and heart medication. And many surgical procedures are studied without blinding, which can still provide useful information if the outcome measures are very objective (like stroke or death). Again – there simply is no valid comparison between this and using modalities that are based upon pre-scientific notions.

Dana Ullman also wrote:

The “team” on which I play is the Hippocratic team, for I honor his “First, do no harm” dictum. I also play on the evidence-based medicine team, not just evaluating short-term but long-term results. I am critical of the use of polypharmacy unless there is evidence that multiple drug regiments have evidence (99% of the time, they don’t).

The statement about “not just short-term but long-term results,” in the context of this discussion, seems to imply that mainstream medicine focuses on short-term results. This is patently not true. There are many long term follow up studies, and it is generally recognized when this is needed.

But let me address the meat of this statement – that polypharmacy, using multiple drugs at once, is not studied “99%” of the time. I don’t know where he gets this figure, but the figure is not as important as the deep misconceptions behind it. In fact, polypharmacy is part of most phase III clinical trials – it is built into basic trial design.

Here’s how: subjects are randomized to either the treatment or placebo arm of controlled trials. The purpose of randomization is to equalize any potential confounding factors that may affect the outcome. Large numbers of subjects are required for randomization to achieve this. Subjects in these large efficacy trials are real patients who have the disease in question, but also have all the other things that real patients have. They are often taking other drugs for other reasons. So the new drug in question is often studied in combination with other drugs that the subjects happen to be taking. And since the net clinical effect is what is measured, the effects of polypharmacy are taken into consideration in such trials.

It is true that certain patients are excluded from specific trials (all trials have their exclusion criteria). This will often include the absence of a major disease that can affect the outcome being followed. It will also typically exclude any medication that can cause the same effects as the one being studied – but this is not always true. Often the only requirement is that there are no changes to the medications during the trial period.

The bottom line is that new drugs are studied in subjects who are taking other drugs, and this provides information about polypharmacy. Also, a great deal is known about so-called drug-drug interactions. Pharmacists are actually quite good at predicting how drugs will interact, and this is information clinicians must master as well. This information is also part of FDA approval and is documented in the official package insert for all medications.

Finally – specific combinations are studied when there is a reason to believe that the combination will have either a synergistic benefit or might produce a negative effect. (I often combine medications that have complementary mechanisms of action – but then of course you have to know their mechanism of action.) But such combinations are the vast minority of all potential combinations – the permutations of all drugs out there is vast and it is literally impossible to test even a tiny percentage of them.

Therefore it is grossly misleading to say we do not have scientific information about polypharmacy, and the 99% figure is meaningless.

Dana Ullman finishes:

There is a good reason that homeopathic medicines are used by hundreds of millions of people today and that historically, it has been used by many of the most respected physicians, scientists, and cultural heroes of the past 200 years.

Ah. The argument ad populi. The logical fallacies are piling up. Blood letting was used for a couple thousand years as well. Millions of people can get it wrong. To deny this is to be supremely naive about the nature of medicine, the placebo effect, cultural beliefs, and the history of medicine. It is possible for a therapy to be widely popular while being utterly useless. Homeopathy, if anything, is proof of that.

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52 responses so far

52 Responses to “Responding to Dana Ullman”

  1. DevilsAdvocateon 24 Mar 2008 at 12:03 pm

    If the homeopathy thing doesn’t work out for him, perhaps Mr. Ullman can land work as the ‘before’ picture in a logical fallacies course.

    Aping James Randi, I offered a Raleigh NC homeopath this challenge: I would put up $1,000 and drink a homeopathic solution of arsenic if she would also put up $1,000. If I died as a result of arsenic poisoning or if I incurred any pathology whatsoever attributable to intake of the arsenic-based homeopathic solution, he’d take the money. If I survived and had no s/sx of arsenic pathology, I’d take his money. Oddly, she refused.

    The efficacy of homeopathy is extremely easy to test and it fails any and every properly designed test. It’s a form of quackery that relies totally on placebic effect, a dishonest practioner, and an ignorant patient base.

  2. DanaUllmanon 24 Mar 2008 at 3:05 pm

    Steven,
    First, thank you for your gentlemanly response. We may disagree on certain issues, but I appreciate your desire to dialogue and your reference to my writings that “grace” your blog.

    To clarify, my comments about surgeons were in the light of the fact that many skeptics of homeopathy assert that only double-blind and placebo controlled trials are the way the determine whether some treatment works or not, and clearly, you’ve shown that this is not always true.

    Likewise, in homeopathy, besides the double-blind trials (which I will briefly discuss shortly), history shows us that homeopathy developed its greatest popularity in the 19th and early 20th century due to its impressive successes in treating infectious disease epidemics. Like in surgery, the mortality rates are a reasonable measure, and the death rates in the homeopathic hospitals were typically one-half or even one-eighth of that in the allopathic hospitals.

    According to the Kaiser Foundation, every man, woman, and child in the US in 2006 was prescribed 12.4 prescription drugs in that year alone…and that doesn’t count the use of OTC drugs. While some studies disallow certain very commonly prescribed drugs from trials, most trials do not provide details about which drugs patients are using, and needless to say, this muddies the water and provides results that are not reliable. Further, most psychiatric medications are tested for FDA approval for 1 or 2 months, even though few physicians prescribe them for such a short period…and new research has questioned their long-term efficacy and has even suggested that many psychiatric medications are as effective as a placebo.

    The bottomline here is that few trials test multiple drugs with any precision. What we call science and what is science is different.

    In light of one of your respondants above, you all should know that there is much more research on homeopathy than most people realize. And sadly, some respondants, like DevilsAdvocate above, doesn’t seem to understand homeopathy (I hope that people who choose to criticize something should make some type of effort to understand it before criticizing it, that is if you wish to maintain a modicum of credibility).

    For the record, there are numerous meta-analyses reviewing the broad field of homeopathy have found that the placebo response is an inadequate explanation for the positive responses observed in controlled trials (Kleijnen J, et al, 1991; Linde, et al 1997). Further, several meta-analyses evaluating the homeopathic treatment of specific diseases has also found positive results, including in the treatment of allergic disorders (Taylor, et al, 2004), post-surgical care (Barnes, et al, 1998), childhood diarrhea (Jacobs, et al, 2003), and influenza (Vickers, Smith, 2006).

    And for those under-informed individuals who say that homeopathy may be helpful but only for self-limiting conditions, I encourage them to do some simple homework. Read about two studies conducted at the University of Vienna Hospital. A randomized, double-blind, placebo-controlled study was performed to assess the influence of the homeopathic medicine Kali bichromicum (potassium dichromate) 30C on the amount of tenacious, stringy secretions from the throat in critically ill patients with a history of tobacco use and Chronic Obstructive Pulmonary Disease (Frass, et al., 2005). COPD is the #4 reason that people in America die. In this study, fifty patients received either Kali bichromicum 30C globules (group 1) or placebo (group 2). The amount of tracheal secretions was reduced very significantly in patients given the homeopathic medicine (P =

  3. Skeptical Caton 24 Mar 2008 at 4:30 pm

    Why stop at arsenic? I’d say make the bet interesting and go for something really lethal…

    For a thousand bucks, I’d happily quaff a standard 30C solution of polonium-210! (Assuming there was no risk of additional solute contaminating successive dilutions, of course) :D

  4. Acleronon 24 Mar 2008 at 6:05 pm

    Dana Ullman Oh, I see, this “gold standard” is not applicable to every medical treatment, nor is it or should it necessary be expected from every unconventional medical treatment either.

    Perhaps it should also be pointed out that because a gold standard trial cannot be performed in certain circumstances, this is no excuse for not using them with homeopathy where it can be easily accomplished. In fact Mr Ullman has tried to publicise several such trials when he thinks it supports his position. Unfortunately, the general conclusion of such trials on homeopathic preparations show little difference from the placebo.

  5. pecon 24 Mar 2008 at 6:20 pm

    Mainstream medicine has strengths, but also weaknesses. Relying on scientific research does not ensure that you will be scientific.

    Here is an example of why: Let’s say there are two different synthetic chemicals designed to treat a certain disease. So you design a double-blind controlled experiment to see which is better. You measure effectiveness by survival time, or decrease in symptoms, etc. And one of the drugs turns out to be more effective and, viola, you have done a wonderful job of providing data for evidence-based medicine.

    What could be wrong with that? Well maybe both of those drugs more or less suck for treating that disease. Maybe synthetic chemicals are not the best approach in the particular context.

    Science is terrific, but like anything human it has profound limitations. Designing and analyzing experiments is the easy part of science. The hard part is finding hypotheses to test. That is a job for rebellious dreamers, not obedient followers.

    Mainstream medicine had considerable success with vaccines, antibiotics, anesthesia, chemicals and surgery, in certain restricted areas. So those are the paths it took and research is confined to comparing treatments that are different but similar.

    It may be reassuring to feel you are on the side of science, and therefore more likely to find the true answer to any question. But you forget, or never noticed, that the scientific method is entirely negative. It’s a method for weeding out bad ideas, NOT a method for generating good ideas.

  6. deciuson 24 Mar 2008 at 6:43 pm

    (I already posted this on the wrong, earlier thread on the same pitiful subject, which I was re-reading for clarity, sorry. Delete it, if possible.)

    Thanks to mr. Ullman for the clarification: the usage of fraudulent rhetorical tactics -akin to those employed by the ideologues of creationism and ID- empower us to discern the merely deluded quacks from the wilfully malicious charlatans. Therefore, we can henceforth count him among the latter, with no fear of hurting his precious feelings.

    I commend you, Steve, for devoting so much of your time to stem such seemingly unstoppable cascades of cognitive dung, propelled by sheer dishonesty and, arguably, greed.

  7. BrianTanion 24 Mar 2008 at 7:03 pm

    pec writes:

    What could be wrong with that? Well maybe both of those drugs more or less suck for treating that disease. Maybe synthetic chemicals are not the best approach in the particular context.

    What excludes a scientist from pursuing an a novel idea that later on becomes a new treatment to be tested in the scientific method?

    Why, for instance, Eva Vertes unconventional idea about Cancer is outside of science or even science applied to medicine? She’s researching to find evidence to support her claim that cancer is just our self-repair mechanism going haywire and that a possible key to a treatment might involve skeletal muscles (cancer being rare there); as one should do. Even as she herself admits it’s a far-fetched idea.

    It might be an actual case of a leap forward in effectiveness of treatment if it turned out to be true. And that’s a major if;

    I don’t think it’s entirely negative to approach things with caution. By all means be rebellious and think outside the box, but make sure the you build a lager box before jumping overboard.

    The only impediment I see is that using science to validate your novel idea before using as a treatment, actually stops you from treating patients without validation. How’s that a bad thing, if you are not, and can’t be, sure that you got things right?

    Anyways, it’s my two cents on this…

  8. Rockoon 24 Mar 2008 at 7:08 pm

    Ullman is profoundly intellectually dishonest; he has had study after study, claim after claim that he relies on comprehensively rebutted, yet this never stops him repeating them elsewhere. His website, for example, makes claims that Darwin was a convert to homeopathy.

    This is patently untrue; a read of Darwin’s letters (all conveniently accessible online) shows what he thought of it – that it was utterly contemptible.

    This has been pointed out to Ullman over and over again. None of this stops him repeatedly claiming it the next time it comes up.

    I often wondered whether the more vocal homeopathy proponents were “just” deluded or were actually much more mendacious. Witnessing the behaviour of Ullman and other online activists, I’ve come to conclusion that it’s the latter.

    I echo what Decius said above about your taking the time to write such a full and reasoned rebuttal to his claims; whilst I don’t think it’ll make any difference to his claims, it’ll leave a trail of reasoned responses across the web which will make the undecided think twice before believing his outlandish claims.

  9. Grimeyon 24 Mar 2008 at 8:29 pm

    To Pec,

    You say synthetic with connotations that make it seem like there is a better alternative. Synthetic drugs are just nature that has been refined to suit our purposes. It’s all just atoms man.

    If there is something in a plant that has some sort of beneficial effect, it is sciences job to find what that is, remove it, refine it, test it so it can be as effective as possible.

    So if you have a cut you could rub a leaf on it that was observed to have a positive effect, or you could take that leaf to your local chemist and have him extract the antibacterial element from it, make sure it’s in high enough concentration, test it for safety, and then give it back to you. You’d probably end up happier with the “synthetic” approach.

    As for hypothesizing, is that not an integral part of the scientific method? You don’t have to look it up, it most certainly is. Make an observation, create a hypothesis, test that hypothesis. Pretty simple, and you’re makin’ science!
    Rebellious dreamers aren’t good for hypothesizing because they tend to throw out the years of thorough research and deep knowledge that human civilization has created. Of course you don’t just want a follower either, you want the third option, a combination of both perhaps.

    To say mainstream medicine has had considerable success is almost an understatement. It’s the only system that has had success, that is why it’s mainstream. If anything else were to have similar success, it would become mainstream.

    That last bit is silly as well, hopefully Steve can explain why exactly.

    Buh bye

  10. Potter1000on 24 Mar 2008 at 8:29 pm

    Pec, what the heck is your “obedient followers” thing? Are you saying that people who are doing typical science are some kind of automotons without vision or creativity?

    And also, what’s with the “sure, science is great for some limited things” attitude? Do you think scientists think that science can be used for non-scientific things? Not only do most people realize the limitations of experiments, but also you seem to be downplaying the practically miraculous things science has accomplished for humanity. I’m not saying we should worship it, but damn, I think it deserves a “woop-dee-doo and thank you for all you do” once in a while, not a “hey, thanks for antibiotics, now go back to your corner.”

    I dare say science kicks the ass of anything else we’ve got going as a species. Can I get an amen, Pec?

  11. Davidmcon 24 Mar 2008 at 8:56 pm

    Wow, Pec, you clearly have an anti-science agenda, because your post makes no sense. If you follow scientific principles, how does that not make what you do scientific?

    All you have done is create a Straw-man argument by hypothesizing a clinical trial of two synthetic chemicals and implicitly excluding some unmentioned natural alternative.

    It wouldn’t be very scientific for a researcher to say that this and only this chemical is effective. In fact, no one says that after a clinical trial. It is that the chemical in question is effective; of course there are other things that may also be effective. That is why medical research continues.

    We’re not idiots Pec, stop characterizing us as ones.

  12. djbmdon 24 Mar 2008 at 10:00 pm

    You mention controlled studies of surgical procedures, and while they are rare, for the reasons you state, there is an interesting example of this in the recently published book The Cure Within: A History of Mind-Body Medicine by Anne Harrington a History of Science professor at Harvard. She has written other works on the placebo effect, the history of split brain work and theories, etc. This book was recently reviewed in the NY Times which mentioned this study in their review.

    In fact, the study as Dr Harrington cites it, is not from a journal but from a NY Times magazine article (in other words I cannot cite it directly). As related, Dr Moseley convinced his IRB to approve a study on arthroscopic knee surgery. Patients were randonly assigned to standard surgery or sham surgery and Dr Moseley did not know which group any particular patient was in until he opened an envelope in the OR. He found that the patients given the sham procedure improved and “not just briefly or subjectively, but on multiple measures of objective functioning”.

    It is not simply the placebo effect at work, but also the expectations of the patient and the relationship with the provider.

    I am absolutely for controlled trials, and have no trouble debunking erroneously information about quacks and charlatans, but I also know that there is an “art” to medicine. Modern medicine is about using that art to delivery useful, safe, tested treatments. But often patients do not have clear diagnoses that fit into one of our usual categories and the tested treatments fail. It is into this situation that the CAM treatments often fall. They work best at preventing illness or managing the supra-tentorial aspects of pain, etc. And, I believe, they do this through the enhanced “art” of their therapies, the relationship with the provider, improved nutrition and overall healthy lifestyle used in most CAM modalities. This is hard to test but is testable. We are seeing more studies of CAM trials making their way into respected journals and this is a good thing. Many studies have been unable to identify benefits for specific treatments but this may be more a methodological shortcoming rather than true evidence of absence in all cases. The British Medical Journal (I think) had a review of the methodological issues when studying a systems approach, such as aruvedic medicine, using a study design used for testing a one step intervention like a drug trial.

  13. wertyson 25 Mar 2008 at 12:38 am

    Ah pec, I haven’t been online for a couple of weeks, and when I come back it’s like good old times with your antiscience trolling. I commend your tenacity, while I mourn for your common sense.

    Dana Ullman lists a number of meta-analyses which he has clearly not interpreted properly (I’ll assume he has actually read them).

    When reporting a meta-analysis one is looking for unequivocal evidence of benefit, in a consistent pattern. The two bog ones he has quoted are now getting quite old, and they both reported that although there was general modest evidence of superiority over placebo, neither found homeopathy had any proven efficacy for any individual condition, mainly due to the poor quality of the studies which made the results dubious. Compared to a meta-analysis of an effective treatment such as aspirin for heart disease prevention, the homeopaths should be professionally embarrassed rather than trumpeting negative meta-analyses as positive evidence, let alone proof of plausibility, let alone actual clinically relevant treatment.

    The rest is just cherry-picking of the evidence.

  14. Nitpickingon 25 Mar 2008 at 7:52 am

    Blood letting was used for a couple thousand years as well. Millions of people can get it wrong. To deny this is to be supremely naive about the nature of medicine, the placebo effect, cultural beliefs, and the history of medicine.

    I believe you mean that denying this is to be supremely naive about the history of science, not just medicine.

    IOW, maggots don’t spontaneously appear in cheese, no matter how many people thought they did.

  15. DanaUllmanon 25 Mar 2008 at 9:46 am

    Wertys is both right and wrong about the meta-analyses. Linde’s meta-analysis (1997) found that there was a 2.45 greater chance of a therapeutically beneficial result from homeopathic medicine, as compared to placebo. However, when reviewing ONLY the high quality trials and when adjusting for publication bias, it moved down to 1.8, which is still significant.

    Wertys is also correct in asserting that the Linde meta-analysis did not find a single condition for which homeopathy was proven to be effective. However, Wertys didn’t report and didn’t know that Linde and team defined “proven” effective as having at least three studies by three independent researchers with statistically significant results. Although this measure was not reached in 1995 (the last date to which Linde’s review included), in 1998, a 3rd study on the use of Oscillococcinum was conducted and again showed significance. Even the Cochrane Report called this body of research as “promising.”

    While the evidence of benefit for Oscillococcinum isn’t as significant as Tamiflu, the homeopathic medicine doesn’t have the “baggage” (side effects) that Tamiflu is known to have. Also, there is increasing evidence that Tamiflu has decreasing benefits as the bugs adapt.

    Also, the 3 studies by Jacobs in the treatment of childhood diarrhea are notable. Although Jacobs was the lead researcher in all 3 studies, she used different groups of homeopaths as prescribers to the children in each study. A meta-analysis in a leading pediatric journal showed significant results. As an additional note, the 1st study that was published in PEDIATRICS showed better results in children with diarrhea who had been infected with a known organism, as compared with children with diarrhea of unknown origin.

  16. Fifion 25 Mar 2008 at 9:48 am

    djbmd wrote – “It is not simply the placebo effect at work, but also the expectations of the patient and the relationship with the provider.
    I am absolutely for controlled trials, and have no trouble debunking erroneously information about quacks and charlatans, but I also know that there is an “art” to medicine. Modern medicine is about using that art to delivery useful, safe, tested treatments. But often patients do not have clear diagnoses that fit into one of our usual categories and the tested treatments fail. It is into this situation that the CAM treatments often fall. They work best at preventing illness or managing the supra-tentorial aspects of pain, etc. And, I believe, they do this through the enhanced “art” of their therapies, the relationship with the provider, improved nutrition and overall healthy lifestyle used in most CAM modalities. This is hard to test but is testable. We are seeing more studies of CAM trials making their way into respected journals and this is a good thing. Many studies have been unable to identify benefits for specific treatments but this may be more a methodological shortcoming rather than true evidence of absence in all cases. The British Medical Journal (I think) had a review of the methodological issues when studying a systems approach, such as aruvedic medicine, using a study design used for testing a one step intervention like a drug trial.”

    Great insights, particularly about the therapeutic aspects of dr-patient relationships (or healer-patient relationships) and the influence this has on both CAM and contemporary medicine. (Though I’m prone to saying that, due to confirmation bias, since I highly suspect that the interpersonal aspects, their psychosocial therapeutic effect, has more to do with why people trust CAM even when the evidence doesn’t support a treatment.) A lot of people can’t and don’t make much of a distinction between feeling “good” and “well”, in the same way that quite a few people have difficulty distinguishing emotional pain from physical pain (or even identifying what emotions they’re feeling). What a lot of people need when they’re making large lifestyle changes (which often have a psychological and social component) is emotional support, which they can get from friends or family, or a commercial/social program like Weightwatchers in some measure or from a cultish approach to eating (raw foodism would be a prime example, where one is entering a new elite – it’s expensive so the placebo effect is greater! – lifestyle that offers all kinds of magical possibilities and the promise of being not only healthier but a superior person spiritually).

    It’s true that gaps in knowledge make it easy for pseudoscientific mind/body types to hijack all kinds of science and inquiry associated with the neurobiological (just look at how much confusion the shaky computer/brain hardware/software analogy is responsible for creating, it’s even the foundation for fiscally successful “spiritual” doctrines and new age practices! *waves an invisible hand and offers a middle finger salute to Ramtha*). In many ways, neurobiology is stepping into the very territory that religion has always claimed as its own (no, not just the creation of life but the mind/body connection…ID proponents of any stripe or star sign aren’t going to give up their position on the seat of the soul easily, it’s pretty much all they’ve got to sell…imaginary real estate in a future life, be it reincarnated or in some version of heaven or hell). While the soul may just be a metaphor, it’s a more accurate one for human experience of being than a computer is! So, while it sounds unscientific, perhaps what is needed is more insight into the soul of medicine as it’s practiced as an art in a clinical setting. It seems quite a lot of lay people get confused about the distance between the research lab and their doctor’s office when discussing science and medicine.

  17. DeeTeeon 25 Mar 2008 at 12:58 pm

    djbmd:

    Dr Moseley convinced his IRB to approve a study on arthroscopic knee surgery. Patients were randonly assigned to standard surgery or sham surgery and Dr Moseley did not know which group any particular patient was in until he opened an envelope in the OR. He found that the patients given the sham procedure improved and “not just briefly or subjectively, but on multiple measures of objective functioning”.

    Moseley compared “sham” arthroscopic lavage of the knee joint to “real” arthroscopic lavage. The active procedure in this case is not “surgery” in the true sense of the word – just a joint wash-out to get rid of debris, and if some loose cartilage was present this would also be removed. This type of procedure was thought to help those with arthritis, but because experience told surgeons that their patients did no better on average to those in whom they did not do any surgery at all and just opted for treatments to improve joint function, Moseley did a trial. (I believe the procedure is very popular with orthopedic surgeons in the USA wishing to make a lot of money for doing very little).

    http://content.nejm.org/cgi/content/abstract/347/2/81

    The results showed improvement in both the sham and real “surgery”, indicating that the “real” surgery was no better than placebo, something many people suspected anyway. people’s expectations were that they should improve with surgery, and this is what happened. I would not use this study as an example of a placebo-controlled surgery study however, since it is a very minor intervention. Comparisons to complex surgical procedures are difficult. No doubt we would find a placebo/expectation effect with other operations too, but it is hard to control for this in practice. The only reason Moseley got his study passed was because it was appreciated the intervention was minor and no clear evidence had accrued to suggest it was particularly useful. It was therefore an ehically acceptable study to perform.

  18. deciuson 25 Mar 2008 at 3:08 pm

    Typical science? As opposed to what, atypical or deviating one?

    Or do you mean a sort of folklore science performed by groups of individuals clothed in regional lab coats?

  19. Potter1000on 25 Mar 2008 at 3:36 pm

    Pec, you seem to have some pretty solid opinions about how most scientists are. I’m not sure why. Most scientists I’m aware of don’t have profound trust in their teachers necessarily, but rather have profound trust in the solid evidence that’s been explained to them. And naturally when we are exposed to so much nonsense in society in general, with endless opinions with very little to back them up, sure it’s easy to respect those teachers who are able to give us something meatier to hang on to, such as rigorously attained scientific knowledge. Sure, scientists don’t necessarily like to have their toes stepped on, but most scientists I’m aware of are entirely committed to pursuing the truth whether or not it contradicts their teachers. But obviously you have your experience telling you otherwise, and it’s not like I can tell you that it’s NOT your experience. It just seems strange, that’s all.

    And I understand that I may have been unfairly missing your distinction between “mainstream medicine” and science in general, but I consider most of mainstream medicine to be a great part and product of science in general. And of course when we think of it that way it’s a great way to see all the progress we’ve made as well as how far we still need to go. But I don’t think the way to go farther is to stop practicing the rigorous (and creative and visionary) work of science. We need to keep fighting the fight, even while people either speak out against mainstream science and medicine or at least show ambivalence towards its power. All I have to think about is one of my kids getting seriously sick, then suddenly mainstream medicine reveals itself as the greatest gift I can imagine (next to my actual kids!).

  20. daedalus2uon 25 Mar 2008 at 5:02 pm

    As someone who thinks of themself as a scientist, I haven’t had a “teacher” in nearly 30 years. That is as long as I have been out of “school”. During that time I have learned a great deal, virtually all of it by reading the literature, some of it by doing experiments myself.

    Everything that I have “learned”, I have evaluated carefully before I added it to my “cornucopia of knowledge” to use a colorful expression. Not a few things have I discarded when I found they were “rotten”.

    It would seem that pec doesn’t actually know any “mainstream” scientists.

  21. pecon 25 Mar 2008 at 5:57 pm

    daedalus2u,

    It doesn’t matter how long we have been out of school. By “teachers” I mean parents, elementary and Sunday school teachers, college and graduate school professors, the authors of books, articles and blogs, friends we admire, etc. Every source of trusted information. It is human nature to believe what we are told, unless we have heard, or experienced, otherwise. The essence of skepticism is comparing diverse sources of information. We can’t help being indoctrinated, but we can avoid being indoctrinated into simple-minded ideologies.

  22. bighouseon 25 Mar 2008 at 7:01 pm

    “It is human nature to believe what we are told, unless we have heard, or experienced, otherwise.”

    I don’t believe you.

  23. DanaUllmanon 25 Mar 2008 at 10:40 pm

    Acerlon has been shown that he doesn’t learn, despite my and others efforts. I have said many times that homeopathic medicine is a system of treating SYNDROMES, not just diseases, and it usually requires individualization of a medicine to the unique syndrome the person has. In fact, the conventional understanding that everyone with, say, rheumatoid arthritis, should be given the same drug is blatantly unscientific in thinking and practice and has no respect for the complexity of disease or of nature.

    One of the beauties of homeopathy is that it is a system in which a clinician prescribes a drug to a patient based on various common and unique symptoms that the person has. Then, because symptoms are adaptations of the organism to fight infection or adapt to stress, the homeopathic medicine mimics the wisdom of the body and initiates a healing.

    I have also said that only in rare situations can a single homeopathic medicine be given to everyone with a specific disease, though we have found positive results with Oscillococcinum for flu syndromes and with Kali bichromicum in symptoms of COPD. Do you get it now? Will you ever?

    My apologies to the newbies here, but some diehard skeptics seem to have such thick skulls that nothing seems to get through.

  24. deciuson 26 Mar 2008 at 8:17 am

    Sure, the blame lies with our thick skull, mr. Charlatan.
    Perhaps your magic water can cure also our condition.

  25. superdaveon 26 Mar 2008 at 10:08 am

    i feel this deserves another mention. Dana proposed that bits of silica break off and interact with the solution in used to prepare homeopathic medicines. This is so mind bogglingly absurd. At the atomic level, there is no reason for bits of broken silica to have any more interaction than the walls of the glass in the first place.

    Also I have a question for you Dana. How is it possible for any drug to have a physiological effect with zero side effects for a drug taken orally? It seems very unlikely to me that every “medicine” used in homeopathy can be so well designed and targeted that they can treat only the disease and cause zero systemic effects. If they are doing something to treat a condition, that physiological effect MUST interact wit the body to do other things.

  26. _Arthuron 26 Mar 2008 at 10:41 am

    Furthermore, Superdave, there is no known expiration limit on homeopatic nostrum, so the putative curative agent doesn’t degrade (or its degradation hasn’t been studied, no surprise there).

  27. DevilsAdvocateon 26 Mar 2008 at 12:59 pm

    Pec: “Science is NOT a way of generating new ideas..”

    That is quite possibly the most ignorant thing I have ever read concerning science. Wow.

  28. deciuson 26 Mar 2008 at 7:38 pm

    Steve hasn’t immediately replied to the further nonsense in this thread.
    A storm is brewing, I say. I bet he is checking out a couple of purported facts before lashing out a scorching rebuttal.

    I can’t wait, really. :)

  29. DanaUllmanon 26 Mar 2008 at 7:56 pm

    Friends,
    I wish that we could ALL be a tad more humble, and I wish we could admit when we don’t know something.
    Some people above incorrectly state that homeopathic medicines do not degrade. Actually, several studies have found that HEAT can and will degrade them. Further, there have now been at least 5 studies using homeopathic doses of THYROXIN 30C placed in the water of tadpoles which slowed down their morphogenesis into frogs. WOW.
    The newest research here found that exposing THYROXIN 30C directly to a cell phone or to an “old-fashion microwave oven” degraded these effects, while having the medicine go through “airport X-ray” had no effect.
    Please know that we homeopaths are interested in knowing what does and doesn’t degrade our medicines. However, we have not yet found a limit to which the process of potentization degrades its impact on biological systems or humans.

    And SuperDave…there could easily be a difference, a big difference, between a medicine interacting with silica fragments in the water as compared with the glass walls. For one thing, one will influence the viscosity of the water and one won’t…that said, I will acknowledge my limitations on the precision of that statement and am open to hear others’ thoughts…

  30. DanaUllmanon 27 Mar 2008 at 12:26 pm

    Aceleron claims to be smarter than the editorial board of CHEST, which is the most respected journal in respiratory medicine. I’m impressed by this arrogance.

    Actually, in the comparisons between control and treatment groups, there were no differences that were significant (see Table 1 on page 938). The only difference in the 2 groups were that 5 of the homeopathic group and 9 of the placebo group had a need for long-term oxygen therapy, though neither the author or journal consider that significant…but even IF it was, this difference in 4 patients does NOT explain the results below:

    The results are in Table 2 on page 939: The homeopathic treated group had 13 in Grade 1, 11 in Grade 2, and 1 in Grade 3.

    The placebo group had 2 in Grade 1, 10 in Grade 2, and 13 (!) in Grade 3.

    (The lower the grade, the healthier the patient)

    Remember, these results are in the treatment of people with COPD, the #4 reason that people in the US die.

    These results are so significant that there are now 2 universities who are working to replicate this important trial.

    Acerlon…please do better homework in the future. Even your fellow skeptics are cringing.

  31. wertyson 27 Mar 2008 at 6:07 pm

    So does Dana Ullman have respect for the scientific method or not? Either he does, in which case he would realise that citing only positive studies without regard for the whole body of evidence is untenable, but on a more basic level as we have pointed out over and over again, the tenets of homeopathy are contrary to the known laws of physics, chemistry, pharmacology or just about any other branch of science you care to mention. If you respect the scientific method, you cannot claim plausible effects where they would be contrary to the known facts of life as we know it.

    If on the other hand you are prepared to support only that science which agrees with your a priori position, you are being intellectually dishonest and intentionally misleading by trying to quote science in support of an antiscientific practice.

  32. DanaUllmanon 28 Mar 2008 at 12:30 pm

    According to TABLE 1 in the COPD trial, there was NO statistically significant differences in the stages of COPD between the treatment group and the control group (p value = 0.178).

    It is interesting how some people use statistics when it works for them and ignore statistics when it doesn’t. As the Church Lady says, “How convenient.”

    As for Benveniste’s research and the “debunking” of him from Nature’s editor, this story is much more complex than you may realize…and I certainly would not call what Nature did as “real science” (as though they could do that in 2 days).

  33. superdaveon 28 Mar 2008 at 4:56 pm

    I’d still like to know, how can something taken orally have zero unintended effects? What mechanism does homeopathy use to obtain such high specificity of treatment?

  34. DanaUllmanon 29 Mar 2008 at 11:35 am

    Superdave…how or why do you say that homeopathic medicines have “zero unintended effects”? And based on your question about “such high specificity of treatment,” it seems that you don’t have much of an idea of what homeopathy is (and isn’t). It’s ok…a lot of smart people know little or nothing about homeopathy, but it seeems that you’re trying to misunderstand it.

    To clarify (a bit), it may be helpful to understand that every substance causes in overdose in human subjects somewhat distinct patterns of symptoms. Homeopaths catalog an immense body of toxicological info.

    Then, clinically, when patients seek treatment for their health problems, homeopaths interview the person and writes down the pattern of symptoms that the sick person is experiencing.

    Using texts and now expert system software, the homeopath finds a medicine that, when given in overdose, causes the similar pattern/syndrome of symptoms that the person has.

    I hope that helps….

  35. Amy Alkonon 30 Mar 2008 at 12:37 am

    There is a good reason that homeopathic medicines are used by hundreds of millions of people today

    Yes, and it’s the same reason people use “Head-On” or “Airborne” (“invented by a schoolteacher!”) — extreme gullibility. Orac did a good piece on this some time ago.

    Here’s a good excerpt from Quackwatch on some of the ridiculousness of homeopathy:

    http://www.quackwatch.org/01QuackeryRelatedTopics/homeo.html

    Stan Polanski, a physician assistant working in public health near Asheville, North Carolina, has provided additional insights:

    .Imagine how many compounds must be present, in quantities of a molecule or more, in every dose of a homeopathic drug. Even under the most scrupulously clean conditions, airborne dust in the manufacturing facility must carry thousands of different molecules of biological origin derived from local sources (bacteria, viruses, fungi, respiratory droplets, sloughed skin cells, insect feces) as well as distant ones (pollens, soil particles, products of combustion), along with mineral particles of terrestrial and even extraterrestrial origin (meteor dust). Similarly, the “inert” diluents used in the process must have their own library of microcontaminants.

    .The dilution/potentiation process in homeopathy involves a stepwise dilution carried to fantastic extremes, with “succussion” between each dilution. Succussion involves shaking or rapping the container a certain way. During the step-by-step dilution process, how is the emerging drug preparation supposed to know which of the countless substances in the container is the One that means business? How is it that thousands (millions?) of chemical compounds know that they are required to lay low, to just stand around while the Potent One is anointed to the status of Healer? That this scenario could lead to distinct products uniquely suited to treat particular illnesses is beyond implausible.

    .Thus, until homeopathy’s apologists can supply a plausible (nonmagical) mechanism for the “potentiation”-through-dilution of precisely one of the many substances in each of their products, it is impossible to accept that they have correctly identified the active ingredients in their products. Any study claiming to demonstrate effectiveness of a homeopathic medication should be rejected out-of-hand unless it includes a list of all the substances present in concentrations equal to or greater than the purported active ingredient at every stage of the dilution process, along with a rationale for rejecting each of them as a suspect.

    .The process of “proving” through which homeopaths decided which medicine matches which symptom is no more sensible. Provings involved taking various substances recording every twitch, sneeze, ache or itch that occurred afterward-often for several days. Homeopathy’s followers take for granted that every sensation reported was caused by whatever substance was administered, and that extremely dilute doses of that substance would then be just the right thing to treat anyone with those specific symptoms.

  36. DanaUllmanon 30 Mar 2008 at 12:36 pm

    Amy,
    Mechanism of action? Ok…only relatively recently did we begin to understand how aspirin works. Please give me the name of ANYONE who didn’t use aspirin in the 1980s or 1970s just because we didn’t understand its mechanism. Please just one!

    As for Head-on…I agree that it is a silly ad, but did you know that ONE of its ingredients was that medicine, KALI BIC (potassium dichromate) that was found effective in the treatment of COPD (because it is known for treating people with thick trachael secretions and for sinus infections)…but please don’t let research get in the way of your beliefs. I’m referring to the study published in CHEST, 2005, from the University of Vienna.

  37. DanaUllmanon 31 Mar 2008 at 12:56 am

    There are plenty of provocative theories about the mechanism of action of homeopathic medicines. The July 2007 issue of HOMEOPATHY had several articles on this subject, some with data and some without interesting hypotheses that do NOT break known laws of physics or chemistry.

    To simply say that there are no plausible theories about how homeopathic medicines may work is simply to be ill- and under-informed of the technical literature.

  38. HCNon 31 Mar 2008 at 6:22 pm

    Funny stuff coming from a guy who keep pulling out his much beloved Chest article, even though it has been shown to be useless with the tiny study group had a very uneven level of COPD impact:

    “First, there were only 25 patients in each group, which is a pretty small number for anything other than a pilot study. You have to remember that, when studies are small, spurious results are more likely to occur. At first glance, the patient characteristics in this table appear pretty well balanced. At first glance. Actually, this is a good example of when statistical nonsignificance doesn’t necessarily mean clinically nonsignificant. For one thing, the stage of COPD in the control group was higher than that of the treatment group (1.20 ± 0.5 versus 1.08 ± 0.4, p=0.178). This seems very odd, because both groups are listed as having mild COPD by this criteria, given that the COPD stages run from 0 to 3, with 0 being normal lung function and 1 being the least severe. If the average COPD stage for each group was close to 1, then why did the patients have such difficulty coming off the ventilator? Something’s odd there, since the mean FEV1 (forced expiratory volume in 1 second) was 54.0 ± 5.3% in the potassium dichromate group and 52.4 ± 5.5% in the control group, both of which are very close to the range of stage 2 COPD (FEV1 between 35% and 49%). In other words, it would seem that most of the patients were bad stage 1 patients.”

    From:
    http://scienceblogs.com/insolence/2007/07/homeopathy_in_thecringeicu_1.php

    This is a blog posting that Mr. Ullman seems to find very flawed, yet he has failed to tell us why.

    He just keeps pulling out his favorite papers, even after he has been told repeatedly that they are crap.

  39. DanaUllmanon 31 Mar 2008 at 10:55 pm

    HCN can find that the patients in this study were more sick than stage 1 (big deal) and he may non-significant differences in the treatment and control group (as one can in the vast majority of clinical trials), but it is interesting to note that he chose to ignore the substantial differences that occurred after treatment.

    Although HCN declared that having 50 subjects in a trial is small, it is interesting to note that the two universities who are presently planning to replicate this trial are using a similar number of patients. It seems that 50 subjects is considered a reasonable number for trials on COPD.

    Finally, it should be noted that smaller trials require much larger differences between treatment and control groups in order to achieve statistical significance…and in this case, there was substantial significance (HCN hates to make reference to the results of this trial or even its potential implications).

  40. Chris Nobleon 31 Mar 2008 at 11:36 pm

    “This is a terrible analogy. Not knowing the exact biological mechanism of action of a pharmaceutical is not the same thing as there being no possible mechanism within the laws of physics and chemistry. You simply cannot compare these two situations.”

    The major difference is that aspirin has an easily demonstrable effect that was large enough to be discovered by trial and error.

    Other drugs have much weaker effect sizes that can only be demonstrated via large random controlled trials. The only way that these drugs can be discovered is via our existing understanding of physiology and pharamcology.

    You need one or the other – either a large easily demonstrable effect or an understanding of the mechanism of action.

    Homeopathy has neither.

  41. HCNon 01 Apr 2008 at 12:47 am

    D. Ullman said “Although HCN declared that having 50 subjects in a trial is small, it is interesting to note that the two universities who are presently planning to replicate this trial are using a similar number of patients. It seems that 50 subjects is considered a reasonable number for trials on COPD. ”

    So you are going on a trial of 50 subjects? Does this have any meaning to you: http://en.wikipedia.org/wiki/Sample_size ?

    D. Ullman continues “Finally, it should be noted that smaller trials require much larger differences between treatment and control groups in order to achieve statistical significance.and in this case, there was substantial significance (HCN hates to make reference to the results of this trial or even its potential implications).”

    Ummm… does this mean that the placebo group being SICKER than the treatment group is a good thing? Oh, I think not! You are being very silly…

    Did you ever post a rebuttal to:
    http://scienceblogs.com/insolence/2007/07/homeopathy_in_thecringeicu_1.php ?

    If you did, where is it? Please share it with the rest of us!

  42. Chris Nobleon 01 Apr 2008 at 1:47 am

    I should correct my previous post. The pharmacological effects of extracts of willow bark containing salicylic acid were strong enough to be found by trial and error.

  43. HCNon 02 Apr 2008 at 1:02 am

    This was interesting… at:
    http://scienceblogs.com/denialism/2008/03/i_dont_usually_do_this_but.php … this posting was described as “Next, Steve Novella once again eviscerates a wacky water-woo cult leader at NeuroLogica. ”

    Not that Mr. D. Ullman would notice.

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