Dr. Walt’s Warning Signs of Quackery

I ran across a series of posts from a physician which I think do a thorough job of identifying warning signs of unscientific, irrational or outright quack medical treatments. They’re not organized in a particularly systematic way, but they cover a lot of important ground. Below are the specific headings grouped under the post in which they appear, with the details to be found on Dr. Walt’s page.

Warning Signs- Post One
1. Is the product or practice promoted as a “Major Breakthrough,” “Revolutionary,” “Magic,” or “Miraculous”?

2. Do the promotions try to simply elicit an emotional reaction rather than present clear information to help you make an informed decision about the product?

3. Is only anecdotal or testimonial evidence used to support claims of effectiveness?

4. Are claims made about scientific support without giving specific details?

5. Is the information about the therapy or product being provided by a professional lacking in the proper credentials?

Warning Signs- Post Two
6. Are technical words used without a clear definition?

7. Would a treatment require you to abandon any well-established scientific laws or principles?

8. Do proponents claim that a medical system is so flawless (“airtight”) that there is no need for further testing?

9. Is the treatment said to be effective for a wide variety of unrelated physiological problems?

10. Is the product a quick and easy fix for a complicated and frustrating condition?

Warning Signs- Post Three
11. Does the proponent of the therapy claim to be criticized unfairly?

12. When challenged, do defenders attack the critic instead of responding to the challenge?

13. Do proponents claim that research will prove their therapy is effective as soon as studies are conducted?

14. Is training to provide the therapy offered only at obscure private institutions instead of accredited professional schools?

15. Do proponents use expertise in other areas to lend weight to their medical claims?

Warning Signs- Post Four
16. Is a therapy encouraged simply because it’s been used for centuries by people in some remote place?

17. Do proponents use statements that are basically true but unrelated to the therapy?

18. Do proponents blame failed tests of effectiveness on skepticism or outright nonbelief of observers?

19. Do proponents claim it is too difficult for most to understand how a therapy works, or that only the “enlightened” can understand?

20. Does the proponent disguise the truth with vague and misleading statements?

Warning Signs- Post Five
21. Does the product you’re considering require advance payment?

22. Does the advertisement promise a “money-back guarantee”?

23. Is the therapy available only in other countries?

24. Are there conflicts of interest?

25. Is the term “natural” the main advantage of the remedy?

Posted in General | 15 Comments

Holistic Vet Asks, “IF CAM doesn’t work, why is it allowed?”

A certain “holistic” veterinarian about whom I’ve written before (here, here, here, and—well, you get the idea) has asked a couple of good questions on his own blog, though not surprisingly I don’t find his answers at all convincing. I’m interested in talking about these questions not so much as a response to the fellow himself, who is beyond even considering any weaknesses in his own philosophy or view of the world, but  because they are truly good questions, and they provide an opportunity to look at some key elements to the persistence of ineffective veterinary treatments despite their lack of efficacy.

The first question was, “If natural therapies don’t work, and I continue to market them to the public and use them in my practice, am I guilty of ripping off the public?” The short answer, is “Yes!” which is part of why I write this blog.

Of course, I have made it clear many times that I doubt most vets, or others, practicing ineffective nonsense therapies like homeopathy, energy medicine, and so on, are actually intentionally lying. I accept that most of them truly believe that what they do is helpful, for all the reasons we all make poor judgments and delude ourselves from time to time. I don’t fault them for their mistaken beliefs, only for their arrogance in refusing to consider the evidence against them.

Rather than offer any evidence for the effectiveness of his methods, the author instead asks a series of somewhat ridiculous rhetorical questions.

Why have I never been prosecuted and convicted of being a con artist?

So the failure of the local DA to prosecute him for fraud proves that what he does works? No, it simply proves that what he is doing is (probably; he rarely offers specifics) not illegal and that he likely really believes it works and so is deceiving his clients unintentionally.

But the issue of illegal claims made on behalf of herbs, nutritional supplements, medical devices, and other CAM interventions is a real one. The law does limit what providers of such products and services can claim. Claims of being able to prevent or treat specific disease conditions are subject to laws and regulations requiring such claims be demonstrated by legitimate scientific evidence. The FDA, Federal Trade Commission, and other state and federal agencies have complex and overlapping webs of jurisdiction over such claims. Unfortunately, these organizations are understaffed and underfunded, and they have neither the resources nor the political will to police individual practitioners or organization.

I once asked a representative of the FDA’s Center for Veterinary Medicine how to best go about reporting illegal claims about veterinary therapies. She sighed and indicated that apart from large companies selling compounded drugs on a large scale, or products that might conceivably be a risk to human health directly or through food production, the agency was unlikely to be able to investigate or respond to such claims. I have, in fact, filed a number of complaints about egregiously and clearly illegal marketing of unlicensed therapies to the FDA and the FTC, and I have never had so much as an automatic email in response.  There are many reasons, practical and political, why unproven therapies are not subject to control by law enforcement, but their underlying effectiveness is not one of these reasons.  

Why do my patients improve when conventional doctors can’t help them?

Of course, he assumes this is true and would like us to assume so along with him. Once again, he offers no evidence of it, and we have no reason to believe it is so since the sorts of alternative approaches he advocates range from the possible but unproven to the outright ridiculous and impossible.

In the absence of any scientific study, CAM providers can claim what they like about the results of their treatments without fear of contradiction, and they frequently do. I could certainly advertise that I save lives where alternative therapies have failed. In fact, I believe I do! But such claims are not themselves proof of anything. Rarely are there direct comparisons of the effectiveness of a CAM treatment versus a scientific treatment, since this is precisely the sort of evidence CAM providers do not seem to feel they need.

Why does the public continue to come to me, seeking the kind of care I can offer their pets that they can’t get elsewhere.

This is indeed a good question, though the implication that people seek his care proves it must work is no more reasonable than the argument that people play the lottery so they must be winning. There are many reasons why people seek alternative medical care:

1. Desperation-As I’ve discussed before, people facing an illness that cannot be effectively treated by scientific medicine will resort to anything that gives them hope or the promise of a better outcome. This is understandable, and no one can be faulted for wanting their beloved pets to be better. Unfortunately, unproven and bogus therapies offer only false hope and often come with the risk of making things worse.

2. Comfort- I don’t know this particular vet, but I do know that many CAM practitioners seem to meet the psychological needs of their clients better than many conventional doctors. A caring demeanor, asking detailed and lengthy (even if medically meaningless) questions about every aspect of the patient’s life, a non-traditional, non-clinical consultation environment, and many other factors can make the genuine caring a CAM doctor feels for their patients clear to the clients.

It is a shame that the traditional medical environment and the time pressure many vets work under, as well as the lack of effective training in communication, sometimes mask the equally genuine caring science-based vets feel for their patients. And, of course, science-based vets are limited in the comfort they can offer by their need to be honest with clients about the uncertainties and limitations of medicine, whereas believers in miracles and magic can freely claim nothing is ever beyond hope of a cure.

3. Philosophy-Many clients seek alternative medical providers because they themselves are believers in vitalistic philosophies or are suspicious of science and conventional medicine for personal or political reasons. I once saw a clients whose dog was in great pain from a bone tumor. the dog would not walk on the affected leg, and he cried piteously when I touched it. The owner had come to me out of desperation after none of the alternative therapies she had chosen to pursue first had made the disease go away. I had some therapies to offer, though not a cure, but she refused to consider amputation, radiation, or other such conventional treatments because she believed them to be unnatural and harmful rather than beneficial. What struck me the most about her beliefs, though, was that she refused to consider any pain medication for her dog and seemed surprised and offended when I offered it. She was having acupuncture done to the dog and using a homeopathic remedy, and despite the obvious pain the animal was in, she really believed these were working, and she certainly believed they were better than “toxic drugs”. People will ignore great even powerful and obvious information if it contradicts what they believe or wish to believe.

4. Control-CAM often involves changes in diet or lifestyle that the client is responsible for. This can give them a sense of control, of being able to actively do something to combat the illness their pet is facing. And CAM therapies are often given along with simple and intuitive explanations of the disease and the treatment, which is more appealing then the often complex, abstruse, and nuanced scientific descriptions of the pathophysiology of the disease and treatment. This too makes the client feel more in control and less bewildered by what is happening to their pet.

The second general question our holistic colleague asks is this:

If natural therapies don’t work, then why does the government (FDA, state licensing agencies, AVMA, etc.) allow me to use them in my practice? Why would the government, especially the FDA, knowingly not just allow but also support the use of natural therapies in the practice of medicine unless they are in on the “scam” too? Why does the FDA regulate homeopathic remedies (which the skeptics claim don’t work) just like they do conventional medicines if these homeopathic remedies are nothing more than “sugar pills?”

His answer?

The only conclusion someone can draw from this discussion is simply this: since the government allows doctors to use natural therapies, these therapies must work and have some value in the practice of medicine. Otherwise the government could easily make it illegal to use natural therapies and prevent doctors from using them. Punishment for using these unproven natural therapies would be swift and severe, such as the loss of the license to practice medicine and possibly even criminal penalties. Since this doesn’t happen, it must be that the government recognizes the value of using natural therapies in the practice of medicine.

Not even close. The reality is that government licensing and regulation is far more about politics than it is about science. As I’ve discussed before, homeopathic remedies were grandfathered in to the original laws establishing the FDA for purely political reasons. And technically, the FDA has ruled that this does not extend to the use of such remedies in animals, so they could prohibit them if they had the political will to do so, which clearly they do not.

Similarly, veterinarians are licensed at the state level, and their activities are limited by the provisions of state veterinary practice acts. These acts are written by legislators, who are clearly not scientists, and they rarely specify precisely what is or is not considered legitimate veterinary medicine. And, of course, we wouldn’t want them to since the science is far too complex and continually evolving to expect e could enshrine it in law. Specific interventions are sometimes legally prohibited, such as declawing of cats in some local jurisdictions, but this is uncommon and, again, driven by politics and public opinion, not sophisticated assessment of the scientific evidence for what constitutes effective or ineffective therapy.

And the professional organizations that represent veterinarians are reluctant to make strong statements about what is or is not legitimate medicine. They are primarily concerned with ensuring that whatever treatments are applied to animals, they are exclusively the purview of veterinarians, a position which has some legitimacy in terms of consumer protection but which also smacks greatly of simple economic protectionism.

Attempts by professional organizations to oppose quack therapies have been made in the past, and these have been met with legal and political counterattacks that have had devastating effects. The American Medical Association once tried to suppress the use of chiropractic for both scientific as well as, admittedly, less laudable reasons. The organization lost an anti-trust lawsuit as a result, and quickly got out of the business of aggressively trying to promote scientific standards where CAM was concerned. And the very existence of the Dietary Supplement Health and Education Act and the National Center for Complementary and Alternative Medicine, both political constructs that have effectively protected unproven and bogus therapies despite all scientific evidence against them, is testimony to the inability of the political process to supervise anything like rational scientific standards for medical practice.

The amount of time this particular vet spends responding to skeptical criticism (albeit without providing any facts or sound arguments to counter it) seems to me to be a good sign. It demonstrates that even the most committed proponents of alternative medicine recognize that such criticisms have weight and influence. We will never banish irrationality, but the fact that even CAM proponents attempt to claim that science is behind their approach and that they often attempt to employ the language, if not the methods, of evidence-based medicine indicates that even they recognize that the public believes and trusts science more than they would like us to think. The facts, unfortunately, do not speak very loudly or effectively for themselves, so we who are committed to scientific medicine must speak for them.

Posted in General, Law, Regulation, and Politics | 7 Comments

ACVIM 2010 Forum– Poster: Vaccination and Immune-Mediated Disease

 Apparent Lack of Association between Primary Immune-Mediated Thrombocytopenia and Recent Vaccination in Dogs
A.A. Huang; J. Coe; G.E. Moore; J.C. Scott-Moncrieff

I’ve written about the proposed association of vaccination and immune-mediated diseases, in particular immune-mediated hemolytic anemia (destruction of red blood cells). For that disease, the evidence is contradictory, and in general it seems likely that very rare cases of immune-mediated disease are triggered by vaccination, but this is not a common or widespread problem, and the vast majority of cases occur from natural exposure to triggers in the environment, probably in dogs with a genetic susceptibility since there are breed predilections.

This study looked for an association between vaccination and immune-mediated thromboctopenia (ITP, the destruction of platelets, necessary for blood clotting). Looking back through medical records at dogs diagnosed with ITP and then comparing them to dogs of similar age, sex, and breed with other diseases, the authors did not find that vaccination increased the odds of developing ITP.

Again, all the usual caveats about small, retrospective, case-controlled studies apply, so these results cannot be viewed as the final word on the question. But even this qualified evidence is more reliable than the wild guesses, hunches, and clinical impressions of those who confidently blame vaccines for diseases like ITP.

Posted in Vaccines | 2 Comments

The SkeptVet on Science-Based Medicine: BARF Diets

I just wanted to let everyone know that I have a guest post out today on the Science-Based Medicine blog, Raw Meat and Bones Diet for Dogs: It’s Enough to make you BARF. I have followed SBM for a long time, and I consider it the premier site for reliable, scientific analysis of alternative medical approaches, so I’m very pleased to have this opportunity to bring science-based veterinary medical information to a wider audience, and to illustrate the relationship between unscientific approaches in both human and veterinary medicine. Hopefully, if the response is positive I’ll be contributing additional articles in the future.

Posted in Nutrition | 11 Comments

From ACVIM Forum 2010– Poster: Injectable nutraceutical for cats

Systemic Effects of a Commercial Preparation of Chondrotin Sulfate, Hyaluronic Acid and N-Acetyl-D-Glucosamine When Administered Parenterally to Healthy Cats

M.R. Lappin; J.K. Veir; C.B. Webb

This poster investigated an injectable nutraceutical containing glucosamine, chondroitin, and hyaluronic acid. I’ve written about glucosamine/chondroitin before, and despite the fact that oral products are almost universally recommended and used in both human and veterinary medicine, there is very little reason to think they are helpful. There is slightly better hope for injectable products, thought the evidence is still pretty lackluster given how long and widely used these products are. Still, with the lack of safe and effective therapies for arthritis in cats, I understand the desire to keep trying these things in the hopes that one of them will eventually be clearly shown to be of some benefit. The cynic in me also recognizes that they are a lucrative area in the pet care market, and that any evidence supporting a new product could translate into better sales.

In this study, the investigators injected the product into 8 healthy cats 5 times over 4 months and measured a number of indices of inflammation, oxidative stress, and anti-oxidation ability (a total of 14 measures alltogether) as well as routine bloodwork and urinalysis at 4 different measurement points.

No change was observed in routine bloodwork or urinalysis. The measure of oxidative stress decreased at 1/4 measurement points. The measure of blood anti-oxidant ability did not change significantly. Of the 12 measures of inflammatory cells and signaling molecules, 4 showed changes. Two types of inflammatory cell counts decreased, one at 1/4 time points, the other at 4/4 time points. Two inflammatory signaling molecules increased,  both at 2/4 time points.

Overall, the study suggests some systemic response to the injection, though only a few of the variables measured exhibited any change. The nature of the change was inconsistent, since some markers of inflammation decreased and others increased. Likewise, the anti-oxidant effects were not robust, with one marker unchanged and the other changed only at 1/4 time points. There was, of course, no control group given that this was a small pilot project, but this makes it impossible to know whether the changes that did occur were strictly due to the product or just the injection process. Also, these clinical laboratory tests are only markers of activity within the body’s inflammatory and anti-oxidant systems, and they do not necessarily indicate any positive or negative clinical effect.

While it is important to conduct such small scale trials to look for safety concerns and to justify further, more clinically relevant research, the data generated here does not strongly suggest the product is likely to have a big impact on inflammatory disease. The authors conclude that, “Some of the findings (decreased oxidative stress, increased anti-oxidant capability, and increased IL10 concentrations) could be of potential benefit to cats with inflammatory diseases and suggest that controlled studies of clinically affected cats are indicated.” This is appropriately qualified (“could be of potential benefit”), but such equivocal findings hardly seem a reason for great optimism, especially given the existing literature on glucosamine/chondroitin products, which is extensive and generally not impressive in terms of supporting a clinical benefit. There’s nothing wrong with further research, of course, and it is true that we lack good therapies for inflammatory urinary tract and joint diseases in cats, but I can’t help but feel this isn’t the most fruitful use of limited research resources, especially given the number of times I’ve had to hear lecturers today say, “At this time, there is no clinical research to support….” with regard to equally or even more pressing problems.

Posted in Herbs and Supplements | Leave a comment

From ACVIM Forum 2010–Poster: Antibodies to Feline Vaccines

I’m currently attending the American College of Veterinary Internal Medicine (ACVIM) continuing education forum, followed by the Evidence-Based Veterinary Medicine Association (EBVMA) symposium, and between lectures, labs, and other events I’m going to try and post tidbits of interest I come across.

This morning I looked at the poster presentations. Posters at scientific meetings are like mini journal articles. They usually report on small studies, often with significant methodological limitations, and they are considered a lower level of evidence than peer-reviewed papers in the journals. This is not a criticism of them as they are a very important starting point for deciding whether to pursue new ideas. It is just important to recognize their limitations and to take a cautious approach to both positive and negative findings presented as posters.

Some researchers are looking at a possibility that leftover bits of feline kidney proteins in vaccines manufactured using cat kidney cells might be a risk factor for immune-mediated diseases which are relatively common in the cat, especially some types of kidney disease and inflammatory liver and intestinal diseases. A couple of papers (1, 2, 3) have shown that cats do form antibodies to some of these proteins after receiving vaccines, but no conclusive evidence has linked this to clinical disease. The concern is a significant one. If it is true, then changes need to be made in vaccine manufacture and use, and there is the potential to reduce significantly an important set of cat diseases. However, if it is not true, then suggestive but inconclusive research on the possibility will only serve to fuel anti-vaccine fears unnecessarily.

The same research group behind the previous papers presented a poster at the ACVIM forum looking for associations between bloodwork values and the presence of antibodies to several feline kidney proteins of concern.

Association Between Feline Antibody Responses to Crandell Rees Feline Kidney (CRFK) Cell Lysates, Alpha-Enolase, and Annexin A2 and Biochemical Abnormalities in 1,477 Privately-owned Cats. J.C. Whittemore; J.R. Hawley; S.V. Radecki; M.R. Lappin

 

 

In this project, blood submitted to a commercial laboratory from 1,477 cats was analyzed. No information about age, sex, vaccination or medical history, or health status was available for specific patients. 16 biochemical measures were compared with the presence of antibodies against 3 feline kidney proteins known to be present in some vaccinated cats. The results were fairly inconsistent and not supportive of the hypothesis that antibodies against feline kidney antigens in vaccines is a cause of disease. For one antigen (CRFK) there was a positive association with one of the 16 measured values, bilirubin (a measure of possible liver disease, among other things). There was also a significant negative association with 2 of the 16 values, creatinine (a measure of kidney function) and alkaline phsophatase (a measure of possible liver disease). The other two antibodies examined both had negative associations with blood sugar, a common blood protein and, for one of them, alkaline phosphatase.

In general, then, these results don’t suggest a strong association between chemistry abnormalities in the blood and the production of antibodies against feline kidney proteins found in vaccines. There was no association with most of the values measured, and most of the associations that were found were negative, which if they were clinically significant might suggest the antibodies somehow protected against liver and kidney diseases, which is highly unlikely.  Given all the limitations of the study, especially the lack of any information about the cats the blood came from, this by no means rules out the possibility that the underlying theory is correct, it simply provides a tiny bit of low-level evidence against it. Undoubtedly, this group and others will continue investigating the problem and will hopefully eventually amass sufficient information for a strong conclusion one way or the other. In the meantime, though, it is appropriate to reassure cat owners that the hypothesis is a real but so far unproven concern, and it is not yet appropriate to alter vaccination practices on the basis of it.

Posted in Vaccines | 6 Comments

Evidence-Based Canine Allergy Treatment

Allergies are an incredibly common, and frustrating, problem in pet dogs. Unlike humans, respiratory manifestations of environmental allergies are not usually very noticeable. Dogs with allergies get itchy skin, and they scratch like crazy as a result. The underlying inflammation and the scratching both lead to secondary infections, especially of the ears and skin.

There are several categories of skin allergies, including allergy reactions to fleas, to foods, and to general environmental allergens such as pollen, dust mites, and so on. There are, not surprisingly, a lot of myths about allergies, and a lot of CAM treatments recommended, as is always the case with chronic disease science does not yet have definitive cures for.  In the future I hope to address some of these, but right now I want to discuss some evidence-based recommendations for treatment of atopic dermatitis (AD: environmental allergies, as distinguished from flea or food allergies).

The veterinary dermatology community seems to have adopted not only the rhetoric but the actual practice of evidence-based medicine more effectively than the profession as a whole. There are a number of published evidence-based reviews of therapies for various skin diseases, and a new review recently appeared titled Treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis. (Olivry T, Deboer DJ, Favrot C, Jackson HA, Mueller RS, et al; for the International Task Force on Canine Atopic Dermatitis. Treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis. Vet Dermatol. 2010 Apr 23 [Epub ahead of print].) After discussing what is known about the cause and mechanisms of AD, the report reviews various treatments for acute and chronic atopy and grades the evidence and strength of the recommendations for them. I have reproduced the grading scales for evidence and recommendations and then collated the findings in the chart below.

Table 1. Categories of evidence and strengths of recommendation

Category of evidence

Ia. Evidence from meta-analysis or systematic reviews
Ib. Evidence from at least one randomized controlled trial
IIa. Evidence from at least one controlled study without randomization
IIb. Evidence from at least one other type of quasi-experimental study
III. Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies
IV. Evidence from expert committee reports or opinions or clinical experience of respected authorities or both
LB. Evidence from laboratory-based studies

Strength of recommendations

A. Directly based on category I evidence
B. Directly based on category II evidence or extrapolated from category I evidence
C. Directly based on category III evidence or extrapolated from category II evidence
D. Directly based on category IV evidence or extrapolated from category III evidence
E. Directly based on category LB evidence
F. Based on consensus from Specialty Task Forces
Modified from: Leung DYM et al. Ann Allergy, Asthma, Immunol 2004; 93:S1–21.

Therapy Recommendation Strength of Recommendation
Acute Flareup    
Identify & avoid allergens Treat for fleas, rule out food allergies, avoid known environmental allergens, beneficial  D
Antibiotics, Antifungals Topical or oral drugs for identified secondary bacterial or yeast infections beneficial  D
Bathing Probably washing more important than shampoo used, beneficial  B
Topical glucocorticoids Short courses very beneficial A
Oral glucocorticoids Short courses if symptoms too severe for topicals, beneficial  A
Antihistamines Not beneficial
EFA (e.g. fish oil) Not beneficial
Tacrolimus Not beneficial
Cyclosporin Not beneficial
     
Chronic Treatment    
Diet trial for food allergy Beneficial if food allergy part of problem  D
Flea Control Beneficial D
Allergy testing Skin or blood testing may detect allergens (not foods) that can be avoided or guide immunotherapy  C
Dust mite control Theoretically beneficial but unlikely to clinically help most dogs  C
Antibiotics, Antifungals Topical or oral drugs for identified secondary bacterial or yeast infections beneficial  D
Bathing Probably washing more important than shampoo used, weekly, beneficial  D
EFA (e.g. fish oil) Helpful in conjunction w/ other therapies, not alone, no particular dose or product, oral only; mildly beneficial  B
Topical glucocorticoids, tacrolimus Beneficial, some adverse effects especially older products  A
Oral glucocorticoids, cyclosporin Beneficial, lowest effective dose to minimize side effects  A
Injectable interferon Beneficial A
Immunotherapy (allergy shots) Beneficial  A
Phytopica (herbal) Steroid sparing effect Ib(evidence)
Antihistamines Not beneficial
Pentoxifylline Minimal benefit, risk too high Ia(evidence)
Misoprostil Minimal benefit Ia(evidence)
Tepoxalin Minimal benefit Ib(evidence)
Leukotriene inhibitors Not beneficial Ia(evidence)
Dextromethorphane Not beneficial Ia(evidence)
Capsaicin Not beneficial Ia(evidence)

Obviously, the text of the review discusses the details of these interventions and the supporting evidence (or lack thereof). The evidence is often of low quality and quantity, but the Task Force has effectively followed the principles of evidence-based medicine in basing recommendations on the best evidence that is available and acknowledging the shortcomings of this evidence where appropriate. Obviously, the strength of their recommendations, and the confidence we as practitioners place in them, should be proportional to the quality of the supporting evidence.

The therapies with the best-documented efficacy, glucocorticoids and cyclosporin, are of course those with the best understood side effects. There is no free lunch in physiology! However, it is also notable that the supposedly safer therapy almost universally recommended in general practice, antihistamines, have little to no evidence of meaningful benefit. It seems likely we give these out mostly in response to the pressure, from the owner and from ourselves, simply to do something. The evidence seems pretty clear that we need to give up this unsupported practice.

Essential fatty acid supplements (EFA, usually fish oils) do have some demonstrable efficacy, but their effects are relatively small and best used to reduce the need for other therapies, such as glucocorticoids, not as primary therapeutic agents. One herbal preparation seemed to have a steroid sparing effect based on a single well-designed clinical trial (Phytopica), but the Task Force was careful to state clearly “Whether or not similar observations would be made with other nutritional supplements has not been established, and care must be taken to not extrapolate these findings to other untested products.”

Such a review is very helpful for the ordinary vet in practice, and while the quality of the evidence is not what we would desire, having it reviewed and explicitly graded in this way is a fine example of how evidence-based medicine can and should be applied in the veterinary field even with the limitations we face.

Posted in Science-Based Veterinary Medicine | 42 Comments

Uncertainty-What It Means and What It Doesn’t

It is in the admission of ignorance and the admission of uncertainty that there is a hope for the continuous motion of human beings in some direction that doesn’t get confined, permanently blocked, as it has so many times before in various periods in the history of man.
Richard P. Feynman

I’ve written before about uncertainty and how it affects medical decision making and also about why pet owners often prefer simple, unambiguous answers to the messy uncertainties of reality. But I’d like to take a slightly different perspective on the issue of uncertainty in science and medicine. The fact that science is incomplete and imperfect is undeniable. Unfortunately, some people take this fact as justification for throwing out the whole enterprise of trying to understand and acquire real facts and knowledge. If vaccines don’t protect us completely, this means they are useless. If science doesn’t know everything, than anything must be possible. These naïve arguments ignore the very clear fact that uncertainty and the impossibility of knowledge are not the same thing.

There are different kind of uncertainty in science. One is the uncertainty of what we don’t know. A big part of what makes science fun is that the universe is so vastly more complex than our little brains that we are never going to be in danger of running out of new things to learn and discover. I like to imagine my own ignorance as a vast abyss yawing before me. Every day I throw in a few grains of sand, but it shows no sign of being filled in. So there is no denying that the surprising and unexpected is out there waiting for us.

But that is not the same thing as saying anything we can imagine is likely to be true. Most of our guesses about the nature of reality turn out to be wrong. Until science came along, this left us fighting over belief systems and led to a bewildering proliferation of different, interesting, and usually mutually incompatible mythologies to explain the world. Now, science is creating the kind of knowledge that works everywhere, in every culture, and that endures through time. Sure, such secure knowledge is only tidbits compared to the vastness of reality, and there is plenty that falls by the wayside. But never before have we been able to have even this much enduring knowledge. Barring the complete collapse of human civilization, we are always going to know that the heart circulates blood, that emotions live in the brain not the heart, that smallpox used to be caused by a bacterium, and so on. What we don’t know is an opportunity, not an invalidation of what we do know.

Another kind of uncertainty, though, is the uncertainty about what we know. Scientists like to say that all knowledge is provisional, tentative and subject to revision. This is true, but non-scientists tend to overread this and believe it means all knowledge is ultimately just opinion and is unreliable. Sure, theories of gravity have changed from Newton’s day to our, but if you have to leave your 8th floor apartment, you can rely confidently on the knowledge that it is better to do so by the stairway than the window. It is possible that gravity will stop working tomorrow, but I wouldn’t bet on it. So while proponents of bizarre ideas like to make much of the fact that scientific explanations are “only theories,” they ignore the fact that those ideas that endure and are refined over time can reach a point where having confidence in their truth makes a lot more sense than doubting them.

A different flavor of uncertainty about the known is statistical or probabilistic uncertainty. I recently put my age, gender, total cholesterol level, and a few other factors into a nifty little calculator that told me I have a 3% chance of dying of a heart attack in the next 10 years. So does anyone know if I’m going to die of a heart attack or not? Can anyone tell me with certainty that I will if I stop taking my fish oil and baby aspirin every day, but I’m safe if I keep taking them? No, of course not. Much scientific research generates knowledge and conclusions that are statistical, that apply reliably to groups but don’t give precise predictions for individuals. So, does this mean such knowledge is worthless for helping us decide what to do as individuals? Of course not.

If you go to a casino in Vegas and play roulette, the odds are you’re going to lose. Sure, you could win. Some people do. But most people don’t. This is a truth, though it is only a statistical or probabilistic truth. So is it worthless in helping you decide whether or not to bet the farm on red? Not at all. Casinos make lots of money betting against you, and you’re a lot more likely to be able to afford that Winnebago when you retire if you play the odds and don’t play roulette. Even though statistical truths apply imperfectly to the individual, they are real and useful guides for our choices. The uncertainty of probabilities does not justify ignoring the odds and doing whatever we like.

Uncertainty is inevitable, in science as in all areas of human life. But this doesn’t mean knowledge is an illusion and blind belief is as good as facts in deciding what to do or not to do. Human beings have changed our planet and our own lives, both for the better and for the worse, through the power of discovering and applying knowledge about the physical world. Such knowledge is limited, incomplete, tenuous, and a damn site better than guessing or hoping. And science has generated more reliable, trustworthy knowledge in the past couple centuries than hunches, guesses, and trial-and-error managed in all the rest of human history. Place your bets, ladies and gentlemen. I’m placing mine on science.

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The Placebo Effect In Song

Happy Birthday, SketpVet! 🙂

Today marks the first anniversary of this blog. Not a momentous event for the world at large, but yet another reminder of the fleeting nature of time for me. Apparently, in the last year I have put up 135 posts and the site has been visited 7468 times. I’ve certainly learned a great deal, about medicine and about writing, and I’ve met a number of interesting people. I hope it has been interesting and useful to at least a few of you.

As an anniversary post, I thought I’d put up something I started on near the beginning but never actually posted.

Last summer, I spent a week at Lark Camp, a folk music workshop/festival/party in the Mendocino Woodlands. I tend to refer to it, affectionately, as Hippie Drum Camp, mostly because I went with the idea of learning to play the bodhran (hence the “drum” part; the “hippie” part should be self-evident). Apart from a brief and agonizing (for me and everyone around me) flirtation with the clarinet in grade school, I have never played an instrument. But I’ve always gone to Celtic cultural events (and pubs) and I know all the songs, so I wanted to learn more about the music. It was a fantastic experience, and I’ve spent the last year trying to learn a couple of instruments so I can go back this summer and participate more fully.

One of the folks I met there was a fiddle player who shared a song he had written called The Placebo Effect. We had a very interesting conversation about his experiences with managing his own diabetes and trying to avoid medication, and about all of the things he had investigated or tried as part of this experience. I had just started this blog, and I thought the song offered some eloquent and funny insight into the issue of placebo effects and unproven or alternative therapies from the perspective of an intelligent, educated non-scientist. At the time, I wasn’t certain he would welcome my making the lyrics public, but I recently found he did so some time ago on his own blog so hopefully he won’t mind.

Apart from the internal merit of the wit and humor, the song illustrates how someone can come to look at the complex relationship between individual experience and scientific knowledge. It is always difficult to argue with someone who feels better after using a therapy, even if the facts are pretty clear that the therapy doesn’t work. Feeling better is real whether or not it means what the person thinks it does or has any relationship to actual physical health.

In trying to promote science-based medicine, my ultimate goal is always to steer people toward what will truly help them or their pets and to steer them away from false hope and the harm that comes from mistaken ideas about cause and effect. But I try always to remember that CAM is popular because it meets a need. It provides hope, even false hope, and it addresses the psychological dimensions of illness in ways that mainstream medicine doesn’t always (though I think this is less true in veterinary medicine for a variety of reasons). I think we can have the best of both worlds–effective science-based medicine and humane, affirming care. But to do this we have to try and understand what appeals to people about CAM and what about scientific medicine pushes them away even when it is the more likely to help them.

This song touches on the issues of uncertainty in medicine, on the fact that general data can’t always predict what will help or harm the individual, and that the slow process of scientific progress, though it is far more likely to reach the right answer in the end, is often too slow to help those who are suffering right now. None of this justifies unproven or outright bogus medicine, but it does explain a bit why even ineffective therapies can be popular, and it reminds us of some of the limitations to scientific medicine that we have to deal with in the effort to guide people towards the best, real therapies available. It also reminds us that CAM is not the sole province of the ignorant, gullible, or stupid. I don’t necessarily agree with the writer’s take on science and knowledge, but from our conversation and his blog I have no doubt he is smart and well-informed. We must be careful not to make the mistake of caricaturing or patronizing those who don’t see the issues around CAM the way we think they are best seen. This blog is as much about learning for me as it is about trying to teach others, and from this fellow and his song I think I have learned a few valuable things.

Oh, and did I mention it’s funny?

In the woods on a sunny day late in July,
all the air was abuzz with mosquito and fly.
In an effort to cope I was spraying some DEET
on my arms, elbows, shoulders,
legs, ankles, and feet,
when a fiddler came by and said
“Don’t waste your time —
there’s no evidence that that stuff
works worth a dime”.
I explained to him I wouldn’t
care if there was,
’cause it helps me so long as
I think that it does.

Chorus:
I would never reject any fake remedy;
the placebo effect is what works best on me.

If I take enough fish oil, I
need not grow old,
if I take echinacea I won’t
catch a cold.
And if I should come down with a
cold anyway,
a few doses of zinc will soon
make it okay.
Now as far as I know there’s no
clinical study
showing zinc really makes you feel
one bit less cruddy.
So it might not be true, yet
I’ve heard that it’s so.
In such matters as this there is
no way to know.

I would never reject any fake remedy;
the placebo effect is what works best on me.

If you can’t afford insulin,
I have heard tell
that ground cinnamon does the job
perfectly well.
There are herbs with strange nicknames
in English and Latin
which I’ve heard are as useful
as Pfizer’s new statin.
I suppose that some day we will
know for a fact
how a body exposed to such
cures will react.
By the time that these answers are
finally found,
I’m afraid I’ll already be
under the ground.

I would never reject any fake remedy;
the placebo effect is what works best on me.

All this week in a tent, yet my
back feels just fine
I assume all that yoga
protected my spine.
And it seems my blood pressure has
come down a bit;
I conclude making music can
help me stay fit.
These are only assumptions, they
may not be true,
and if I wanted proof, well,
my options are few.
For, to test your health habits, there’s
one thing to try:
life your life over different
and see if you die.

I would never reject any fake remedy;
the placebo effect is what works best on me.

And it really is not just good
health that’s at stake,
for the thoughts that we live by
are most of ’em fake,
and we get through each day by
accepting as right
every half-assed conception
we dreamed up last night.
If I master this dance, then it
means I’m no fool,
if I wear the right clothes it will
mean that I’m cool,
and if I could play well every
tune on this list,
it would prove to me I have a
right to exist.

I would never reject any fake remedy;
the placebo effect is what works best on me.

Though to say it out loud here takes
plenty of gall,
I think music’s the greatest
placebo of all.
For as long as we’re playing we
think life is fine
and the wide world around us is
not run by swine.
Through a skeptic might ask what
this fake joy is worth,
at least fake joy’s the kind you can
have here on earth.
So that moral that I would leave
with you is this:
do not seek tragic wisdom
where bullshit is bliss!

I would never reject any fake remedy;
the placebo effect is what works best on me.

Posted in General, Humor | 4 Comments

JAVMA Article on Electroacupuncture for IVDD

A couple of readers have asked me to comment on a study that appears in this month’s Journal of the American Veterinary Medical Association, Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing neurologic deficits.

The study was performed in Brazil at the School of Veterinary Medicine and Animal Science in Sao Paulo, where a similar study published last year and another in 2007 were also performed. The authors created 3 study groups, all of which consisted of dogs that had severe neurological disease of >48 hours duration attributed to intervertebral disk disease (IVDD). Group 1 (DSX) was a group of dogs (N=10) selected retrospectively from patients that had undergone surgery for IVDD at the authors’ hospital between 2003 and 2006. Group 2 (dogs treated with electroacupuncture-EAP, N=19) and Group 3 (dogs treated with both surgery and electroacupuncture-DSX+EAP, N=11) consisted of dogs seen at the hospital between 2006 and 2008, and patients were assigned to these groups based on their owners’ choice.

All dogs were treated with oral steroids. Dogs in Group 1 were treated surgically with a couple of different techniques and presumably with whatever unspecified medical treatment and post-surgical care the individual surgeon elected. Dogs in Group 2 were treated surgically (and again presumably with additional unspecified followup care) and were also treated with electroacupuncture. This treatment consisted of the insertion of metal electrodes into the body at points determined by “traditional Chinese theory.” Electrical current was passed through these electrodes for 20 minutes weekly for from 1-6 months. Scores were assigned to quantify the level of neurologic dysfunction initially and at 6 months after the beginning of treatment. Improvement was judged based on decrease in neurologic score and regaining the ability to walk unassisted.

The results can be summarized as follows:

  DSX EAP DSX+EAP
Score Unchanged 6/10 4/19 3/11
Score Improved 4/10 15/19 8/11

 The text indicates that the proportion of dogs in the DSX group that improved was statistically significantly lower than in the other two groups, and the proportion of DSX dogs that remained unchanged was significantly greater than in the other groups. From this, the authors concluded that “EAP was more effective than DSX for recovery of ambulation and improvement in neurologic deficits in dogs with long-standing severe deficits attributable to thoracolumbad IVDD.”

So is this conclusion justified? I believe not. To begin with, of course, we must decide what if anything this paper has to do with “acupuncture.” Electroacupuncture has been referred to as a bait-and-switch, because it is arguably not acupuncture at all. Obviously, the ancient Chinese lacked electricity, so the theories and guidelines developed for acupuncture in humans are not really relevant to the effects of electricity on the body (there were no specific guidelines for animals, and despite claims to the contrary it does not appear the Chinese routinely practiced acupuncture on animals before the mid 20th century). There is, however, a scientific medical therapy involving electrical stimulation to treat pain, transcutaneous electrical nerve stimulation (TENS). The only difference between TENS and electroacupuncture appears to be the selection of electrode location. TENS places electrodes in locations associated with known nerves, and in electroacupuncture the electrodes are placed at acupuncture points with no consistent relationship to any identifiable anatomic structures. However, by chance or perhaps some trial and error experience, some acupuncture points do happen to coincide with the locations of nerves, so it is possible that electroacupuncture might effectively be the same thing as TENS in some cases. So one might justifiably question whether any benefit seen in this study represents a validation of the theory and practice of acupuncture or an example of TENS with irrational selection of electrode locations.

However, there are other reasons to view the authors’ conclusions skeptically. A major methodological flaw of the paper is the process of selecting and assigning subjects. It is highly likely that there are biases inherent in allowing owners to choose what treatment group their pets should be in and in selecting one group retrospectively from one period of time and another prospectively during a different time period. This process does not allow the owners or researchers to be blinded in any way to the treatment, and it makes it likely that the patients and the treatment they receive in the various groups will differ with respect to many variables other than the one of interest in the study. The lack of blinding is of particular concern since the research center has consistently produced papers showing positive results for electroacupuncture and thus the researchers likely have a strong a priori bias in favor of the approach.

Very little information is presented to allow us to evaluate whether the patients differed in meaningful ways in terms of the medical therapy, surgical care, and post-surgical care they received. We do know that the EAP and DSX+EAP subjects received weekly treatments at the hospital for from 1-6 months after the onset of the study, and it is likely that they received much more intensive followup and post-surgical care (for the DSX+EAP group) as well as better owner compliance due to seeing the doctor so often after the study commenced. It is also quite possible that the differences in outcome were due to any number of differences in the populations of the various groups or the biases of the authors since these were not controlled for effectively.

There are other methodological problems, particularly the small number of subjects, but overall the two factors already discussed are enough to make me question the strong conclusions the authors draw from their results. It is certainly possible that electrical stimulation of some parts of the body could have a beneficial effect on outcome for dogs with neurological deficits attributable to IVDD. Better studies involving random prospective allocation of subjects, more consistency in the treatment of the subjects, blinding of the researchers and owners, and perhaps more precise assessment criteria would be valuable. I would be particularly interested, if there turns out to be some value to so-called electroacupuncture for this condition, in seeing a comparison of this procedure with electrode locations selected according to anatomic structures such as nerves compared with locations selected according to traditional Chinese medicine principles (insofar as such principles can be called “traditional” with respect to treating animals with electricity). It would take a robust and repeatable superiority of treatment at traditional acupuncture points compared with locations selected according to the principles of TENS to convince me that this procedure has anything to do with acupuncture.

Posted in Acupuncture | 19 Comments