Jul 27 2010

Maloney Declares Victory

Christopher Maloney does not get it – on many levels. Some of my regular readers may remember a few months ago when a naturopath by the name of Christopher Maloney frequented the comment section of my blog, making outrageous claims and generally getting a smackdown from the other commenters. I occasionally joined in until it was clear that Maloney was not engaging in fair and substantive discussion. Well now Maloney has copied much of this exchange onto his own website and has declared victory.

I will get to the “meat” (perhaps tofu is a better term) of his claims in a moment, but first will recap the exchange. The exchange began with this blog post in which I reported the accusation that Maloney complained about another blogger who was then temporarily shut down by his blog host. Maloney denied the accusation, which I reported as soon as he did, and clarified that the accusations were only alleged. It then came to light that another CAM practitioner, Andreas Mortiz, was responsible for complaining about the blogger, and I immediately updated my original blog post with that information. That is pretty standard blogging practice, and in fact was rather diligent in providing updated and corrected information as it became available.

Maloney, however, wanted something more. I think he just liked playing the role of the injured party. Meanwhile the substance of my original blog post (and a subsequent one naming Maloney) was about the health claims that Maloney was making on his website (more on that below).

In any case, this sparked the exchange that Maloney is now calling “The Novella Debates.” Incidentally, as further evidence that Maloney doesn’t “get it”, he reproduces my entire blog post, and many comments from my blogs, on his site without my permission, and without even the minimal courtesy of a link back to my website. This is considered stealing content – Maloney, the accepted practice is to provide an excerpt or leading paragraph with a link back to the original post. I officially request that you change your website accordingly, and provide a link back to every comment you quote.

That breach aside, Maloney spends a lot of time dodging the substantive questions put to him by whining about my lack of attention to his comments. Actually, he simultaneously claims that I should be too busy as an academic to give him any attention, and then complaining that I am not giving his comments enough attention. He seems to think that I monitor and actively participate in every comment section of every post I have written, without limit. He also seemed perplexed by the notion that I “let” my readers debate for me. Well – I was not aware we were in a debate. He does not seem to understand the blog format: I write a blog post, and then readers are free to comment and discuss among themselves. I comment occasionally as warranted, but am always putting up new posts and therefore don’t follow all my old posts.

But let’s get to the substance of Maloney’s claimed “victory.” Initially Maloney, apparently trying to bait me, and engaging in the tu quoque logical fallacy, claimed that science-based medicine kills patients and does not work. He gave as examples the treatment of hypertension, depression, and ear infections. I and many readers pointed out that the references he selectively quoted did not support his position – he misinterpreted the very evidence he gave to back up his points. In fact, modern treatments for hypertension work. For depression, you have to divide between major depression (good evidence for efficacy) and minor depression (weaker and controversial evidence for efficacy). And for ear infections he did not seem to get the fact that I support the evidence-based standard of care and criticize those physicians who deviate from this by overprescribing antibiotics.

But finally (because the name “NeuroLogica” and the description of this blog as being about neuroscience, and my bio were not enough clues for him) Maloney got the fact that I am a neurologist and so we focused on neurological treatments. He wanted to discuss 5-10 neurological diseases (because he likes the Gish Gallop), but I focused on one – ALS. I wrote:

But if you want to play – let’s focus on ALS. Tell me what magical new treatments you have for ALS that I have somehow missed.

The challenge I put before him, because this was relevant to our discussion, is to inform me about an effective treatment for ALS that derives from naturopathy/alternative medicine that I missed because of my focus on science-based practices. The details here are important because, as you will see, Maloney later moves the goalpost. This was his response:

Turns out your colleagues in Seattle already came across the same idea, but I don’t think you’re using it yet. It involves Clostridium difficile causing a portion of the ALS cases. I came across this idea when I was researching possible ALS support and I found a small study on stool analysis of ALS patients. About 1/3 had significant Clostridium overgrowth, but I can’t find the study on medline listed under Clostridium. I assume the Seattle neurologists must have found the same study.

So here’s the thought: if a portion of ALS patients (peripheral onset?) are genetically susceptible to the relatively mild Clostridium difficile toxins then a stool analysis would give a possible treatment option: systemic antibiotics and the addition of Sacchromyces boulardii. Previous trials with antibiotics and ALS haven’t focused on the possibility of an antibiotic resistant organism causing the problem. I think the addition of S. boulardii is essential to provide competition to C. difficile regrowth.

Maloney references a paper in Medical Hypotheses – a journal notorious for publishing highly speculative notions of dubious scientific merit. In fact, the journal editor was recently replaced over this, with the promise of better peer-review in the future. You see what Maloney did – I asked for a treatment for ALS and he sent me a wild speculation. Further, this speculation comes from mainstream scientific medicine – not naturopathy, and not anything that can be considered “alternative” – even by the fuzzy definition of that term. So he failed to meet the two criteria of my challenge.

He then tried to turn it back on me – saying that I should somehow take up his suggestion as a research priority. This is a hopelessly naive statement. I belong to an ALS research consortium. The primary purpose of this group is to discuss and determine clinical research priorities for ALS. This is important because resources are limited. Specifically, ALS is a rare disease and patients do not survive long, so it is difficult to get large numbers of patients into trials. This means that we need to focus our clinical research on the most promising approaches. Maloney, however, with no expertise and no involvement in ALS research, thinks he can set our research priorities after a few minutes of searching on Medline. (He also does not understand that ALS clinical research requires cooperation among many centers, as no one center sees enough patients to enroll sufficient numbers into a trial.)

I further pointed out that the lack of follow up publications probably means that the researchers themselves did not find any promising results, or else they would be running with that ball. Essentially, more preliminary research would need to be done to show that this approach would be promising before I would even get involved as a clinical researcher.

Having failed with that response, Maloney then shotguns with supplements:

Megadoses of vitamin E- good safety profile and short term benefits, no long term benefits or long term side effect picture.

Antibody screening for celiac disease- several reports of celiac mimicking ALS

Any of the following supportive therapies: creatine, folic acid, alpha lipoic acid, lyophilized red wine, coenzyme Q10, epigallocatechin gallate, Ginkgo biloba, or melatonin?

Again – Maloney fails to make the case that any of this is “alternative” or derives from naturopaths. In fact, this is all coming from science-based medicine. He further puts his foot in his mouth by writing:

Given Dr. Novella’s dismissal of any possible bacterial link, I’ve moved on nutritional supplements as support for ALS patients.
…I am truly interested if Dr. Novella is using any of the supplements in clinical practice, but I suspect that he is dismissive of any supplementation.

Maloney displays the black and white thinking typical of cranks – I never dismissed “any possible bacterial link” with ALS. I simply pointed out that the hypothesis is not very plausible, especially in light of previous trials with antibiotics in ALS, and that therefore more basic science evidence would be necessary to warrant clinical attention. His suspicion that I am dismissive of supplements is also based on his own prejudices, not mine. He thinks that supplements are somehow alternative – but that is his label, not mine. I had even previously clarified that I subject all claims to logic and evidence, and don’t discriminate based upon the “alternative” false dichotomy. Maloney displayed no comprehension of my explanation.

In fact – I prescribed creatine for a few years to my ALS patients, with full informed consent that it was not a proven therapy and was experimental but with some good animal data. That is – until several clinical trials showed no effect (here is an updated review concluding no effect). The ALS research group to which I belong actually conducted the largest trial of creatine (also negative). I actually change my practice in response to new evidence. The final nail is probably not in the coffin of creatine for ALS, but any possible effect is likely to be so small that it is not worth the risk and inconvenience of taking the supplement (there is the potential for kidney damage if not used carefully).

I also prescribed Coenzyme Q10 to my patients for a while, based upon preliminary evidence and the likelihood of safety. However I stopped after a clinical trial found no effect. In fact, if you look at the list of authors on that study you will find one “Novella SP” – here’s a hint, Maloney – that’s me.

Made clear by this exchange is the difference between the science-based approach and Maloney’s approach, which is typical of naturopaths. I look at all the evidence for plausibility, safety, and the reasonable potential for benefit. If I am convinced that I can offer my patients the probability of benefit in excess of harm, I will use a treatment (no matter how it is labeled) with proper informed consent. But I will then closely follow the evidence and will stop using a treatment if good clinical evidence is negative. Or I will start using a treatment when new evidence shows that it is safe and effective.

Maloney, on the other hand, appears to trade in wild speculation. In my opinion he has demonstrated sloppy, black and white thinking, an inability to understand the implications of published research, a bias against science-based medicine, and a willingness to prescribe treatments based upon the flimsiest of scientific justifications. He then accuses me of being “dismissive” and has the stones to declare victory in our exchange because I eventually tired of his evasiveness and crank tactics.

Further, Maloney, if anything, has demonstrated that the naturopathic/alternative approach has nothing to offer. The science is the science, and properly using scientific research as a basis for practice is the ideal of mainstream medicine. The optimal standard of this is what I have termed  science-based medicine. Maloney, however, is laboring  under the false dichotomy of “alternative” medicine. As evidence of how ultimately worthless this false category is, he pulls from the scientific literature to find alleged alternatives to science-based practice. He claims that supplements are alternative and “suspects” that I would ignore them because of this, when they have received research attention in accordance with the basic-science evidence without discriminating based upon their “supplement” status.

The big picture is that so-called “alternative” medicine is nothing but a deliberate distraction from the thing that really matters when it comes to medical treatments – what is the science behind them. Are they safe and effective, and how do we know?

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