Jul 01 2008

Deconstructing the Cranks

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Comments: 23

Regular readers may have noticed that I occasionally get hostile comments in my blog. I would be shocked if I didn’t – in fact I would worry that I was not doing my job if I did not regularly infuriate the purveyors of nonsense and promoters of anti-science. I frequently respond, even to the most inane of such comments, if I think it will be instructive to point out common fallacies and misconceptions.

Sometimes I view comments from a sociological point of view – they may demonstrate a social phenomenon worthy of discussion.

I recently received this comment in response to my blog on facilitated communication. Gigi Jordon (writing as “Holly Light”) commits so many fallacies that any meaningful treatment requires a separate blog entry, so here it is. She begins:

Hey Steve Novella,

What a load of arrogant pseudoscientific self aggrandizing tripe. Truly!…….. First of all I used to observe from an relatively anonymous standpoint patients being seen at the most elite levels of academic medicine on the east coast over a period of 10 years being treated for lets say motor neuropathies. These patients, inevitably would become frustrated with the limits of either the treatments offered or the bedside manor of their physicians or some combination of both, and go to another equally pedigreed academic neurologist say……….Latov or Dalakis , et. all…………. It was a big joke among my cohorts at the time that every time the patient switched to a new big wig in academic neurology, say every 3-5 years on average, and for the lay audience, I’m talking the best neurologic specialists in this highly specialized field of medicine in the world, people Steve Novella would look up to by the way…….. The patient would get a new diagnosis! MMN (multi motor neuropathy), No wait – now it’s CIDP! (chronic inflammatory demyelinating polyneuropathy), no, no, wait its dermatomyocytis!
So brilliant are you all at the mental masturbatory facility of your “science”. So very objective!

Holly opens up with the “arrogant” gambit. This is a cheap shot that anti-intellectuals frequently trot out because it’s easy. Any pretense to knowledge can be attacked as “elitist” and “arrogant” – it is an attempt to get people on your side by implying, “This person is not one of us regular folks, they think they are better than us.” It is a dismissive ad hominem logical fallacy – attempting to dismiss a person’s position by attacking the person.

Here Holly isn’t even addressing the point of the blog post, facilitated communication, but rather is going off on an irrelevant rant about neuromuscular disease. In her attempt to “poison the well” by denigrating me professionally and intellectually, she is attacking academia, scientific medicine, and my specialty. At least she is exposing herself to any discriminating reader.

Holly also demonstrates the true arrogance of those who equate their tangential knowledge with expertise. One theme I promote in this blog is proper humility when dealing with areas of knowledge in which one is not an expert. This does not mean you cannot have an opinion – but one should fairly account for the consensus of expert opinion and be wary of those who casually dismiss it.

Holly seems to be impressed with her knowledge of neuromuscular disease, but demonstrates that (as she admits) she has the limited knowledge of an outsider who does not truly understand the subject. She criticizes the fact that neuromuscular patients are often given different diagnoses by different recognized academic experts – as if this calls into question the entire field. Here’s the real story (and just FYI – this is my particular area of expertise).

There is a category of diseases known as immune mediated neuropathies – auto-immune diseases in which nerves are the target. All auto-immune diseases are difficult to categorized specifically because they are not discrete diagnostic entities – one disease tends to blend into the next. This is particularly true of immune-mediated neuropathy. Add to this is the fact that there are different ways to classify them – by clinical syndrome, by physiological characteristics on nerve conduction study, or by the presence of specific pathological antibodies. These various classification schemes do not overlap very well – meaning that patients with the same antibody may have different clinical syndromes, for example.

For this reason there have been confused, evolving, and at times competing schemes for specifically classifying these diseases. One person’s MMN might be another person’s CIDP. But progress is slowly being made, and efforts are underway to standardize the diagnostic scheme as much as possible.

Further – the patients that are being referred from one specialist to another are the ones that are slipping through the cracks in the current diagnostic scheme. If someone has typical MMN and responds to the accepted treatment for MMN – they don’t get referred for a second opinion. So Holly is referring to particularly challenging patients with a particularly challenging category of diagnoses. She does not put her example into any meaningful context – I suspect because she does not understand the context, and she seems content with her self-serving interpretation and gives no evidence of having tried to understand the context.

And yet this is all supposed to vaguely call into question what? – scientific medicine?

Holly continues:

Then let’s move on to the vast array of medications that you utilize to treat these (and all) patients ( this will get to facilitated communication later my friends worry you not!). If you look at the PDR (again to the lay audience, the “bible” of prescription medications it’s basically listing of all of the FDA required information for approved prescription and over the counter medications in the US), and look under mechanism of action (or how does this drug work?), you will find that in over 85% of the drugs in use today helping patients cope with disease, they (read medical community) have absolutely no idea how the drug works. They usually venture a guess but are very cautious to disclaim not really knowing the true bio-physiological effect of the drug. So they have no idea.

The ignorance false dichotomy – equating not knowing everything with knowing nothing. And again this is just an attempt at impugning by association my arguments regarding facilitated communication.

The PDR is indeed a key reference for medications. Holly calls it the “bible” of medications – which is an attempt to portray it as a dogmatic source, rather than a systematic reference of scientific data. But she also does not get it quite right – there is a great deal of information on many medications not contained in the PDR. The PDR contains essentially the official required FDA package insert of information for each drug, but many drug studies are done and published in the peer-reviewed journal outside the context of FDA approval. In practice the PDR is just a slice of the scientific information on pharmacotherapy.

Holly’s clearly stated point is to exaggerate the apparent ignorance of scientific medicine when it comes to drug mechanism. This is a flawed line of reasoning on many levels. I have already addressed that her factual premise – the PDR contains all relevant information – is wrong. I also pointed out that she is equating lack of complete knowledge to “they have no idea.” Let me address this point.

Any honest reading of the PDR – a thick and ever growing tome – reveals how incredibly much we do know (at a minimum) about all the drugs we prescribe. The PDR is a testament to our vast knowledge, not our ignorance, as Holly would have you believe. But it certainly is true that we do not know the precise mechanism of action of every drug. That is not the same thing as having no idea, however.

For most drugs we at least know some or all of their physiological actions. For example, we may know what receptors they bind to, the effect of the drug on that receptor, and the physiological function of that receptor. We may not know, however, how that action has its ultimate effect on the symptom or disease that is being treated (these are areas ripe for further research). Also most drugs have more than one effect, and we simply may not know which effect is the important one for any specific application.

For the vast majority of drugs we have a great deal of information about how they work, and a good idea about their specific effects on the symptoms and diseases we use them to treat. In fact many drugs are classified by their mechanism of action (like beta-blockers, for example). Others are classified by their use, but knowledge of their basic mechanism of action is key to their use. I lecture on neuropharmacology and I emphasize the importance of understanding the known mechanisms of action of the drugs we use, while also recognizing the limits of our current knowledge. Summarizing all this as “we have no idea” is absurd – it is the kind of statement that someone who is overly impressed with their own limited knowledge would make.

Now that she has mangled her premise, she follows up with the logical fallacy (and another false premise):

In fact, in the “old days” (think pre–1990’s) the academic medical community actually had some balls and were willing to humbly defer to the fact that we don’t and can’t know everything but should offer the benefit of exploiting and using drugs that are helpful even if we don’t know exactly HOW they work.
Now, (read post 1990 or so) our cowardly doctors in the name (and spirit of Novella above) have taken up the shield of “evidence based medicine” to cower from pressure the insurance companies and HMO’s, setting new standards for the use of new discoveries to not help patients saying it’s not enough that a drug works,we have to know how it works to offer it to patients! The truth is the doctors gave yup fighting the insurance companies using this new”standard” and adopted it as their own to not look as insipid and cowardly as they really are. Give it a big harvard name “evidence based” and all is well, don’t worry about what we’re supposed to be doing in life like, oh yea curing disease. just publish papers about nothing (read of no clinical significance, i.e to help anyone get better or lead to true clinical advancement in treatment). Then you’ll do real well in medicine. Oh, and then write some sniping articles about pseudoscientific practices like FC and sneer all the way home thinking how you don’t make as much money as your fathers generation when adjusted for inflation – gee I wonder why?

Here Holly is simply making stuff up – or regurgitating anti-scientific propaganda that others have made up. This is a complete rewriting of history from a rather bizarre point of view.

First – the FDA does not require that any information pertaining the mechanism of action be presented in order to approve a drug (which ironically was her previous point). The FDA requires only that the drug is proven safe and effective for a specific indication. That’s it. So it is simply not true that in the past we did not require knowledge of mechanism but now we do. As long as there is adequate evidence for safety and efficacy it is reasonable to use a drug (or any treatment). Knowledge of mechanism makes it easier to use a drug rationally and effectively, and of course this also helps progress our medical knowledge, but it has never been a pre-requisite to accepting a treatment.

This is a straw man preferred by promoters of unscientific medicine – it is an attempt to make the rejection of their fake treatment or claims on the part of scientific medicine seem unreasonable. But it is simply a fiction.

Next Holly completely misrepresents evidence-based medicine. This is a new one on me – EBM was invented by the insurance companies and adopted by physicians out of laziness. Wow. That will come as a surprise to the Cochrane Collaboration. The goal of EBM, ironically, is to focus on evidence for efficacy – not mechanism of action. In fact, even more ironically, that is my primary criticism of EBM, that it does not adequately consider mechanism of action when dealing with highly improbable therapies.

Finally, Holly gets to FC:

Now to facilitated communication, Steve, motor planning 101. I had a friend who was a professor of psychiatry he was 80 at the time but still played tennis every week, unbelievable fit, looked like 60. So we used to meet and 1 week he doesn’t show up. Brusk message on my voice mail sounding irritated from him instead of apologetic about canceling after the fact. Next week I go to meet him and I see him in his car outside the tennis club parked just sitting and not getting out of his car. I go and knock on the window. He looks startled and peels out of his parking spot leaving me in the street. @ weeks later he’s diagnosed with a frontal lobe tumor which was thankfully removed and he recovered nicely. He later told me that he had been very irritable and found himself in multiple situations where he would go somewhere to do something and was then paralyzed in an inexplicable way from initiating the activity at hand, in my case it was getting out of the car. He knew why he was there he knew what he wanted to do – HE COULDN”T INITIATE THE VOLITIONAL ACTIVITY REQUIRED TO CONDUCT THE MOTOR PLAN STEVE.

Volitional inhibition, ever heard of it Steve? The list of specific dyspraxic disorders are legion. So the crime of ignorance you commit as as an “expert neurologist” is harmful in the extreme to so many people locked in a world of silence by ill informed opinions that have given so little thought to the issues at at hand. It annoys me to no end (this I’m certain you ARE aware of by now) because your have the training and background of thought to give so much more sensitive consideration to the subject were you not blinded by arrogance. You assume cognitive dysfunction where in fact there is nothing more than a global dyspraxia of volitional movement. Just another ill defined motor disease Steve.

Holly’s unstated major premise here is that disorders of communication are motor dyspraxias – the inability to speak due to a motor problem, even when the cognitive ability is there. She gives a long wind-up to this basic premise, but it is all a huge non-sequitur.

Yes – there are many neurological disorders that involve a problem with the motor aspects of speech and not the cognitive aspects of language. Neurologists are very careful to distinguish such things. I treat many patients with various motor problems impairing speech, and there are a number of legitimate methods for helping them to communicate – none involve FC.

Other patients have impaired language – a cognitive impairment involving the language centers in the brain. These patients require different interventions, like speech therapy, or augmenting their communication with non-verbal methods. Again, FC is not useful.

And a third category have neither an isolated motor or language problem but an impairment of global cognition. It may be their ability to think that is impaired – not their ability to express what they think.

What, exactly, is Holly’s point? She does not make it clearly. Is she saying that there is no such thing as a language disorder or global cognitive impairment? That all non-verbal patients have a motor problem and not a language problem? How does she presume to know this, and why should anyone think that her knowledge is superior to the experts in the field? Oh yeah – that’s right. Anyone who disagrees with her is an arrogant coward, while she has enough tangential knowledge to use the occasional technical term.

Even if she is only claiming that in some cases a motor disorder is mistaken for a language or cognitive disorder – again how would she know this and why would she presume that dedicated clinicians are not making a serious effort to make such distinctions.

She continues:

Of course they can’t be put in a stringent double blinded testing environment with a wall between their helper and them. It’s antithetical to the process.

That’s like taking a post stroke patient who cant talk and trying to grill them in an “objective testing environment” to see whether gentle supportive encouragement and therapy to help them retrieve words and produce speech using patience and multisensory reinforcement helps them to talk. But if they can’t perform as well when stripped of that support in a cold and advesarial testing , let’s say sitting in a room with a tester being drilled on vocabulary, claiming that supportive speech therapy is a hoax if the patient didn’t perform nearly as well as within the confines of a known trusted speech therapist providing support and giving the person needed cues or time.

This is the “My woo cannot be tested by your cold indifferent science” gambit. This is a straw man and amounts to nothing more than a lame excuse for the absence of compelling scientific evidence for FC.

FC makes a specific claim – that the non-verbal client has hidden language ability that can be tapped into with help. I have nothing a priori against this claim – I just recognize that it is important to find out if it is really true, in general and in specific cases. This is especially important if allegations of sexual abuse are going to be based upon this assumption.

The claim of FC, (again – in general and in specific cases) can easily be tested – simply give specific information to the client while the facilitator is out of the room, then allow the facilitator to use FC in whatever way they feel comfortable to convey that information back. No walls are necessary, no artificial controlled environment. The only thing that needs to be controlled is the access of the facilitator to the information you are testing for. When tested in this simple way, FC completely fails. A rational response to this utter failure is to question the assumptions underlying FC. An irrational, ideological, arrogant response is to rant about “cold and adversarial testing.”

She finishes:

Let’s just throw out speech therapy too, why should we presume that the person has the cognitive ability to speak?

Why because they did it before………..Ignorance guides your thinking about people with communicative dysfunction related to “developmental delay”. They have voice you just refuse to hear it.

Let me see if I have her logic correct – we can know that people who lost the ability to speak have the cognitive ability to speak because they had it before they lost the ability to speak. OK – but what if they lost the ability to speak because they lost the cognitive ability, and not just the motor ability? What if a patient has aphasia because a stroke destroyed the language center of their brain? That is not a motor problem – that is a language problem.

But also – this does not mean that there is no role for speech therapy – and all patients with aphasia do get speech therapy because the brain has plasticity and perhaps the aphasic patient may be able to recover some speech. But sometimes they don’t.

Holly then draws an analogy between someone who was cognitively normal at baseline and then suffered a stroke or some damage to their language center and those who are developmentally delayed. She seems to be concluding that we should therefore assume that even those who have a completely distinct neurological situation (developmental delay) also have normal cognition and an isolated impairment of language. She gives no justification for this assumption. Common sense tells us that such an assumption is not warranted, and this is backed up by the evidence.

I, on the other hand, am not making any assumptions that any individual does have impaired cognition. My education and experience tells me that every permutation is out there – including those who have relatively normal cognition but impaired communication or language, as well as those who have impaired communication because they have impaired cognition. Each individual needs to be assessed individually.

Holly is just dodging the real question by attacking her straw man. The question is – in any situation does FC work? How can we be sure that the facilitator is not the one doing the communicating? Holly and other FC apologists would have you believe that by asking such questions we are being cold, we are refusing to listen to the evidence, and we are being mean to these children. The truth is, not asking these critical questions is neglectful, irresponsible, and sometimes tragic.

I want people with all kinds of neurological impairments and challenges to be helped by methods that actually work – ones that are based upon science, not wishful thinking and sloppy logic.

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