Wednesday, October 27, 2010

Addressing the comments

A very lively discussion indeed! Thanks to everyone who contributed, and thanks for keeping it civil, mostly.

A couple of thoughts on some of the comments:
1. Craigmont: "Between the testable and the untestable; between science and woo; there can be no middle ground. You're going to have to pick a side."
Really? There is no middle ground? I have to choose a side? Really? I am pretty sure that this is how we advance a discussion or knowledge. Seems to me that this is a good way to get elected to office these days, as well as sell news. But does it really get us to a better, more advanced place? I think not.
2. Timm: "You may not have meant the term "allopathic medicine as derogatory, but that is indeed, what it is. It is a slight, a slur, a marginalization.Many people these days recognize what it refers to and do not (as you) intend it as a slur, but it remains a belittling term."
OK, Timm, the point is clear, even though there is nothing that seems to suggest its derogatory nature other than who coined it. This notwithstanding, I am perfectly happy to respect your experience of the word and not use it in any way. But here is what I need from you: 1). Please, tell me what term you would like me to apply to Western medicine that differentiates it from other? and 2). Do you think that "woo" is a respectful way to refer to the other side? Or perhaps you think that "those people" do not deserve your respect, so it is OK to use derogatory shorthand. Either way, if we are interested in advancing the issue in some direction, there has to be a civil conversation between the opposing sides. So, I would suggest that we aim for that, and the way to start is to stop calling each other names, knowingly or not, as you pointed out.
3. Liz Ditz: "To me, high uptake rates for all vaccine-preventable illnesses, including those you characterize as minor (varicella or chicken pox) are a social justice issue. The social and economic costs burden of vaccine-preventable diseases falls disproportionately on those least able to pay for them: the poor and the working poor."
Liz, can you please say more about what you mean? I think that I understand, but want to be sure that we are talking about the same thing. Thanks.
4. Ian Monroe: "They are constantly talking about what a complicated process science is. And it is a process, not an answer. Of course the media is pretty much a four-letter word on their blog."
Yes, Ian, and I am constantly talking about it on my blog as well. And to me, even though I share similar understanding of evidence as the SBM group, my conclusions are different. And they are not only my conclusions. And this is why it is important to have this conversation: in science, as in anything else, you can look at the same data, and walk away with very different lessons. This is why I advocate an open-minded conversation between the opposing sides, rather than just throwing grenades at each other across an imaginary separating line.
5. Calli Arcale: "Homeopathy, in the traditional sense, should be harmless except insofar as it causes people to delay effective treatment. However, what is sold today is not strictly homeopathy in the traditional sense."
Dear Calli, can you show me a study or a body of evidence that indicates the presence of a delay, the magnitude of that delay and the real consequences of it (i.e., morbidity and mortality)? Something that can be specifically attributed to it, rather than the patient's own reluctance to present to a physician for a work-up? In other words, I am interested in the attributable outcomes of what you are referring to. As for your second point (and this was brought up by several commenters), can someone tell me how the mechanism of recalling the harmful stuff from the market is different from these preparations than it is for conventional pharmaceuticals? Thanks.
6. Opit: "Sorry. You've lost."
 Really? Somehow I do not feel like I've lost. Somehow I feel like I've won. The discussion is enriched, the tone is more constructive, and we are actually getting to the issues. Contrary to our political discourse, this is not a zero sum game. My aim is not to walk away with the same opinions that I started out with or making the chasm between us more prominent. My desire is to understand the issues better and to have a respectful conversation about stuff that we feel is important. So, while I thank you for your strategic advice, I will not be following it.
7. moderation: "As to the varicella vaccine, I think you have fallen victim to 'I have not seen it, so it must not exist' syndrome."
Dear moderation, while it seems to be the habit to draw inferences about people in the conversations that I have seen in other blogs, I would prefer it if you did not do so here. Most of the time, as I try to teach to my students, these inferences will be incorrect. I think we should stick to the arguments that have been made, and if you want to extend it to inquiring as to whether or not I have fallen victim to denying the invisible (in this case a bad thing), please, inquire away first. Now you have to go back and come up with a different hypothesis, alas. And if you sense a little bit of snideness in my remark, please, forgive me this transgression, as I am so wary of people assigning labels to others based on what they want to see only and not in what is really there. 
8. Orac: "Ah, yes, the 'just asking questions' gambit."
Really? Come on! You don't mean that asking questions is anti-science, do you?

I am grateful to see that Dr. Novella has posted a response to my response. His response seems measured and inviting to a respectful discussion, and I particularly appreciate that. I will take the time later to address some of his points further in a different post. In the meantime, let the discussion continue. I would love the answers to my questions above, so that I can get educated further on these issues.

As ever, thanks!  


  1. "Do you think that "woo" is a respectful way to refer to the other side? Or perhaps you think that "those people" do not deserve your respect, so it is OK to use derogatory shorthand."

    Apparently you think it's perfectly fine to refer to vaccine defenders as "rabid":

    May I assume that you believe that those of us who argue for the safety and efficacy of vaccines don't deserve your respect?

  2. Orac, you are correct, and I have already apologized for setting a confrontational tone, and will do so again. Confrontation gets us nowhere. So, again, apologies.

  3. ***1). Please, tell me what term you would like me to apply to Western medicine that differentiates it from other?***

    How about 'medicine'? There is no such thing as 'Western' medicine.

  4. Well, David, OK, but I think that many a Chinese person may disagree with you, as in Asia they still practice traditional Chinese medicine and refer to it as such. So, if we are to have a respectful and cogent discussion, we need to find respectful and cogent ways of referring to one another.

  5. On a short note: if you want to keep the discussion civil maybe you should possibly stop answering to criticism with insults and actually, ahm, come up with some arguments!

    On a not so short note: So, I guess what you are saying is that everyone is somehow right in some sense in his own very special way? Well, I guess then we can all just go home and stop doing science altogether. While the thought that in science we can all agree and respect each other and everyone is right might be appealing (to people that like unicorns and pink fluffy clouds), it is just simply complete bullshit! Science is not politics, it's not about agreeing, it's about finding the right answers to questions!

    Science is not about saying everyone is right, it's about finding objective ways to tell which theories have merit and which don't. And saying that we need to respect 'woo' and can't call it mean words is also just a very weird thing.

    Or are you suggesting that physicists should please start respecting catholic zealots that claim that the sun revolves around the earth (to my massive surprise, those actually exist)? I mean, calling such ideas utter nonsense given the accumulated evidence is really very, very disrespectful! What a bunch of evil, arrogant, paternalistic physicists disrespecting those geocentrists!

    And yes, in the end, you might just have to pick a side, either you think that evidence should tell you which scientific theory has merit, or you can think that everyone is somehow right. In that case, you might wanna change your job to something, ahm, non-sciency!

  6. Thanks, Anonymous, for your comments. If I have been insulting in my responses, please, let me know where, and I will try harder to refrain from insults.

    To say that there is no middle ground on our clinical science is to misunderstand the whole field. The tools we have are far from ideal, if you ask two people their opinion on any study you will get at least two different opinions, and the way to arrive at progress is to listen to each other. My views on many of the topics that we have discussed are shared by many prominent clinical scientists and philosophers, as I did not arrive at these ideas in a vacuum. No, I do not support the tea party, I am not a creationist, so perhaps you are frustrated because you cannot neatly file me in any wingnut category that you are used to. But please, I would really appreciate it if you could get beyond your sarcasm and start thinking about there possibly being at least two sides to this argument.

  7. Marya,

    How about "(proven) medicine" and "alleged treatment"? The latter emphasizes that you haven't taken a position on whether or not the treatment works, and that you are open to having it shown to work. If you have taken a position on it and you think there is evidence to suggest it doesn't work, or is no better than placebo, calling it an "ineffective treatment" seems fine, as does the colloquial term "bogus".

  8. Hello, SirMoogie, I would ordinarily say that yes, proven medicine would be great. However, I refer you to many other entries on this blog, as well as much peer-reviewed evidence to suggest that much of what we consider certain is far from it. So, if you can find "proven" medicine, then definitely, I will fall on the side of proven.

  9. Okay, Dr. Zilberberg-

    I bring my sick child into your practice. You diagnose him with a dangerous and fast-progressing yet treatable bacterial infection.

    Which CAM modalities will you consider?

  10. Craigmont, the evidence for antibiotics is pretty solid, so I would of course offer antibiotics. If you were also interested in having a reiki practitioner present while your child was being treated with antibiotics, I would certainly not object.

  11. Would you recommend any CAM therapies, or prescribe medicine alone?

  12. Craigmont, since I am not a CAM practitioner, no, I would not prescribe CAM.

  13. "I would ordinarily say that yes, proven medicine would be great. However, I refer you to many other entries on this blog, as well as much peer-reviewed evidence to suggest that much of what we consider certain is far from it. So, if you can find "proven" medicine, then definitely, I will fall on the side of proven."

    I suspect by "proof" you mean logical necessity. I suspect you mean this as you mentioned Hume's criticism that science cannot have logical proof (the key word here is "logical") and you used the word "certain". This is not what most individuals mean when they say "proven", and it isn't the case among scientists. What most lay people and scientists mean by "proven" is given all the relevant information available it is probably the case that X (where X is some claim that follows from the information). This is of course not logical necessity, but to say that what we have proven in science isn't logically necessary is a very weak claim. It's logically possible that people could spontaneously regrow lost limbs. A set of propositions that are not contradictory is a logically possible set, and the number of examples we can construct are limitless.

    To illustrate how silly it is to expect logical necessity before accepting a claim. Suppose you were the prosecutor on a murder case and you had DNA evidence linking the alleged murderer to the victim, a murder weapon in their possession with only their fingerprints, and several independent witnesses and you were asked for proof that the suspect committed the murder? Do you think it is reasonable to say, "I have no proof as it is logically possible the alleged murderer didn't commit the crime"? Isn't it the more reasonable response to say, "Yes. We have proof. The presence of the murderer's DNA at the crime scene means it is likely he was there. The fact that his fingerprints are the only ones on the murder weapon means it is likely that he used it for the murder. The fact that three people that do not know the victim or the murderer saw him do it, means it's likely he committed the murder."?

    Most people do not use "proof" in the logical sense and the way Hume was using the term, and I wasn't either. Nor are scientists when they claim a certain treatment is proven effective for treating some condition.

  14. SirMoogie, thanks for your explanation. Alas, in clinical science in many respects we are far from having the smoking gun with fingerprints. If you are interested in my reasoning, I invite you to read deeper into my blog, where I discuss much of the evidence, as well as evidence that is lacking. If only clinical science were that straightforward.

  15. I don't think clinical science is straightforward, nor crime scene investigation. I just think waiting for logical necessity (certitude) is impractical.

  16. If you could pick one treatment you covered where you think that there is consensus among scientists that it is proven to be effective, but you think is has compelling evidence against its efficacy, that would be a great place to start. Does any one of your postings come to mind?

  17. SirMoogie, the mammography debate is qute illustrative. I actually blogged about the evidence (or it's lack) over a year ago, well before the new reds ignited the controversy. Also take a look at some of my posts on VAP. Thanks.

  18. I've posted a comment on my own blog as SBM won't let me register and my comment was too long for this blog.

    This is the executive summary-
    Effective exchange of views and knowledge relies more on discussing specific concrete real-life facts than being polite to each other.
    The SBM website is primarily an anti-woo advocacy site and as such not primarily a site for discussion of issues of medical science.
    One cannot assume that public opinion pieces against CAM achieves better outcomes for real patients.
    Pro- or anti-CAM discussions are inherently boring.
    Framing disputed points of view as ethical or unethical is an exercise in bad faith.
    Calling a professional colleague a 'dipsh*t' doesn't reflect well on yourself or your associates.


  19. Marya, you should learn to listen better to what people say. I do not think that you are a creationist or believe that the sun revolves around the earth. And I never said that. People that support a certain type of pseudoscience seldom support _all_ available types of pseudoscience. How could they? There is really quite a few of them and most of them are extremely crazy.

    However, your view that scientists should 'respect' pseudoscience and are not allowed to call it what it is: utter nonsense, bullshit, or simply 'woo' is quite questionable in my opinion. Thus, the example with the geocentrists (a quite extreme type of pseudoscience supported by very few people): science does not need to respect people making crazy stuff up and calling themselves scientists! And when Orac and SBM criticize 'woo' it is exactly that: crazy shit that people made up (just like geocentrism, though that some believe is supported by 2000 year old books)! It often is even crazy dangerous stuff that people make up to earn a lot of money.

    Why do you think that scientists should not be able to call crazy made-up stuff crazy made-up stuff?

  20. Thank you, Anonymous, for your advice. To respond to your question, I think that scientists can say whatever the heck they please. I also think that it behooves us all to do better at listening rather than trying to out-shout each other -- just look what has happened to our politics. Do we really want medicine to continue going in that direction? Confrontational tone and baseless accusations turn people off, and they simply stop listening to your message, no matter how valuable.

  21. Marya, so you think stating that the sun does not revolve around the earth or that water is not a medicine (apart from for dehydration) or that waving hands above someones body is not a medical intervention is a 'baseless accusations'?

    Extremely interesting, I think you might want to rethink your career choice.....

  22. Dear Anonymous, thanks for your advice once again. I think it may be my turn to ask questions. Here is one: How far has the shouting gotten you and yours in getting your point across? Can you cite some evidence that your approach is working? Is there biologic plausibility that this approach should result in the desired opinion change?

  23. Well, I guess if it's not working, they are right! The sun does revolve around the earth! Water has memory! The earth is flat! You should call some physicists and also tell them to stop accusing those poor poor geocentrists and flat earth supporters. It's really not working!

    But let me think, actually, it does work! Most people know basics of science! Science is taught in school! And I wonder how we got there. I guess by telling pseudoscientists that they really do have a point and in the end, we don't actually know anything because the world is oh so complicated. In the end, do we really know that the earth is not flat? It sure looks flat to me!

    Knock yourself out, pseudoscience works after all, at least for you I guess......

    I guess if it wouldn't be so sad, it would actually be funny that a 'scientists' (by that I mean you), thinks one should not call bad science bad science because 'it's not working'. You really do have a severe problem with logic.

  24. Dear Anonymous, I apologize if I was unclear in my questions. What I would like to know is, have the shouting tactics that I see employed by both sides to convince the other that they are wrong worked well? Are converts lining up at your door? Or is everyone retreating farther and farther into their corner? you may think that this is how we reach understanding and that science taught through confrontation is the recipe for success, but is that really so?

    And nice job answering your own question.

  25. Well, I guess if telling the truth is not working, we should stop doing so! That sounds like an excellent solution to the problem of pseudoscience!

    But I have to remember that one should first proof that saying what one thinks in clear words and discussing all evidence is working before one does so. This is indeed a very interesting approach to all kind of problems.

    (I hope you realize the sarcasm)

    And since you are unable to answer the question: should scientists be allowed to call pseudoscience nonsense (you seem to think no), I am off, this is an utterly useless discussion.

  26. Dr. Zilberberg,

    Back to our hypothetical patient:

    Would you suggest that I seek out various CAM practitioners to supplement your "allopathic" treatment, since you "don't have all the answers?"

    If not, why not?

  27. Craigmont, this is a fair question. No, I would not recommend any CAM because a). I am not a CAM practitioner, and b). I have not personally seen enough benefit to understand when and where it can or should be useful. I can accept its placebo value in a therapeutic situation, if that is how it works, and I do not object to letting my patient benefit from its placebo effect in addition to my therapeutic trial. So, as I have already said elsewhere, if my patient wants to consult with someone, and if I am not concerned about interactions or adverse effects, I will not put up road blocks to that contact. If, on the other hand, the patient was interested in a treatment that I felt might be detrimental, I hope that, like any other dangerous health behavior (smoking, driving drunk, unsafe sex), I could build enough of a relationship with that patient to dissuade him or her from pursuing it.

    Since I am wary of having my words distorted, I think that this is a fairly general situation with a general answer. Now a question for you: if I had a patient suffering from back pain, and upon a thorough work-up I found nothing treatable other than with pain relievers, do you think that I should forbid that patient from pursuing massage, if he seems to think that is may be helpful?

  28. Dr. Zilberberg,

    (I should disclose to you that I am not a doctor and not qualified to advise you on diagnoses or advice to patients. My point in this line of questioning is only to divine and clarify what you're advocating.)

    Massage, at least, has a plausible mechanism by which it might provide temporary pain relief.

    If this back pain patient is adamant that he wants to try colon cleansing, chelation therapy, and a Rife elctromagnetic machine, what would your advice be? If this patient brought one of these practioners along to argue with you, how would you react?

  29. Craigmont, my guess is that this type of a patient would have already tried all these (whatever the Rife machine is) before ever consulting me. But if he had not, I would probably first spend some time probing him on what his understanding of these modalities was and what using them meant to him.
    I generally think that the more one is willing to work with the patient's belief system, the better, provided that it does not interfere with my prescription and does not pose a threat to the patient.

    I think that we can take this to a ragged extreme. This in no way advances the understanding of how to wield evidence from clinical research responsibly, which I believe is a much more productive discussion. When we lose 400,000 people to smoking, another 100,000 to medical errors, another 99,000 to resistant hospital-acquired infections, it is not really of interest to split hairs about modalities that at worst may pose a small risk, and at best just do nothing, other than provide the patient with a modicum of psychological comfort. I would not frown on their religious activities, so why should this bother me?

  30. I'll wrap up and quit bugging you.

    You don't care much about CAM one way or the other, which is fine. But in practice, you have no use for it either for your patients or yourself (I would presume.)

    If you don't support CAM, then don't support CAM.

    There is a debate going on, and all you've shown is that you think everyone should play nice and you won't be pinned down.

    I say this with respect and appreciation for your time. In a meeting of your peers, I wouldn't have the credentials to be in the room.

  31. Craigmont, thanks, I feel that the exchange has gotten us to a better place. Is it not a shame that you feel that you do not belong in a meeting with my peers? You have all the credentials you need. You just need to have these ideas demystified in English. You are smart enough to understand.

    Thanks for advancing the conversation with me.