House, M.D.

Ever since St. Elsewhere -yes, I am really, really old- I am addicted to hospital series, from ER to Grey's Anatomy. My favourite, since I like caricature, and the overt references to the House of God, is Scrubs. There are more series, and one of them is annoying beyond description: House, M.D.. Apparently nobody shares my dislike.

Why do I have a problem with this particular series?

1. House simultaneously works as a paediatrician, gynaecologist, nefrologist, gastro-enterologist, radiologist, surgeon, et cetera. For some reason his hospital does not need medical specialists. Internists do know alot but those I have met never attempt to be any other type of physician.
2. Oddly enough, his diagnosis will ignore more obvious possibilities, and instantly requires us to accept a more unlikely scenario.

The first point should be self-evident, the second I will explain in more detail. Let me be absolutely clear, in no way am I suggesting the presented diagnoses are incorrect. One can argue that technically every episode is medically possible. Whether the sequence of events is plausible is something else.

From experience I can tell you that the series explores medical conditions that rarely, at initial presentation, offer sufficient information to instantly suggest their highly unusual diagnoses. The list of enigmas, i.e. uncommon diagnoses, I encountered consists of:

• Systemic Lupus Erythematosus (SLE), initial presentation: severe thrombopenia
• Idiopathic Thrombocytopenic Purpura (ITP), initial presentation: severe thrombopenia
• Glanzmann's thrombasthenia    
• Autoimmune hepatitis   
• Heparin-Induced Thrombocytopenia (HIT)
• Transfusion Related Acute Lung Injury (TRALI)
• Ogilvie syndrome    
• Toxic Shock Syndrome (TSS) which, within four hours after being admitted to A & E, developed into Multiple Organ Dysfunction Syndrome (MODS)   
• Stevens–Johnson syndrome    
• Irreversible brain damage because of prolonged hypoxaemia following acute and severe carbon monoxide poisoning   
• Carotenaemia evaluation jaundice after visit to the tropics  
• Fièvre boutonneuse evaluation after visit to the tropics, GP thought of malaria (in case of fever + tropics malaria should be the first in your DD) 
• Lassa fever    
• Wolff–Parkinson–White syndrome (WPW)  
• Dissectio aortae requiring a Bentall procedure    

Only carotenaemia (jaundice without yellow eyes), and fièvre boutonneuse (eschar), were an on-the-spot-diagnosis, the others involved extendsive investigations. Eventhough I worked in highly regarded hospitals, no physician was able to pull any rabbit out of his hat. House, of course, would have known the answer within seconds. Utterly unrealistic, especially those that invlove a diagnosis per exclusionem, it is ridiculous to let House skip the exclusionem part.

Add to that the convoluted, and at times incomprehensible, decisions and you understand my being underwelmed. In all honesty, his diagnostic and therapeutic approach are so aberrant it immediately removes any credibility for me. Even the caricature Scrubs has an air of authenticity.

His Asperger-like antisocial personality I find less offensive, it resembles many physicians I have worked with. Totally incapable of thinking of others, and convinced of their infallability. Admittedly, like House, they do tend to know their stuff. Strangely enough this part of the character is true to life.

His magician-like ability to conjure up the right answer out of thin air makes me incapable of watching the series.

Ideology using legalities to stifle scientific critique

Throughout history many have found ideology to be a trustworthy window on reality. As such it is the basis of many misconceptions. When science increased our knowledge of the world surrounding us inevitably this contradicted many beliefs. The solution people have found to that contradiction is the following:

1. Confronted with evidence your opinion is flawed you amend your view accordingly, 
2. Confronted with evidence your opinion is flawed you amend (read: ignore, or misrepresent) the evidence accordingly.

Anyone interested in sanity, and reason, will adopt option 1. Of course, the anti-science movement, without exception, chooses option 2.

This is because the intrepid ideologue will start by simply denying anything that contradicts his/her erroneous opinion since the Galileo-gambit proves he/she is right. This method is not without risks. More and more people realise they are the victim of propaganda. Another avenue for maintaining your discreditied position is legal bullying. As we have seen, in the case of Simon Singh, litigation -using the U.K.'s libel laws in particular- is a preferred method, employed by cranks, of removing science-based criticism from public discourse.

The latest incarnation of the "let's-prohibit-those-pesky-reality-based-objections-to-our-nonsense"-method resulted in cancelling the publication of Paul Offit's latest book Deadly Choices: How The Anti-Vaccine Movement Threatens Us All. It is discussed by Orac describing how he:

found out about this when a British blogger, who had been originally sent a copy of Dr. Offit's book to review, received an e-mail from Dr. Offit's British publisher, Basic Books, requesting the review copy back and informing the blogger that "for legal reasons we have had to cancel the publication of this book." I had to tell the blogger that I had no idea what this was about, but it didn't take me long to find out that Richard Barr was threatening legal action against Perseus over one sentence.

He continues to note:

that usually the goal of cranks is not to win a judgment, but to shut down criticism by any means necessary. To that end, even though it would have been pretty pointless for Barr to sue Dr. Offit directly, legal threats against his U.K. publisher are very effective. All Barr has to accomplish is--if you'll forgive the term--to raise the bar on the costs of publication to the point that publishing Dr. Offit's book can't be profitable. Given the low profit margin of most books, likely Dr. Offit's included, a few legal fees spent to fend off threats like that of Mr. Barr go a long way towards discouraging publishers from publishing critical or controversial books. That's the point.

Unfortunately, the anti-science movement, like Hydra, appears impossible to debilitate. The purveyors of woo disingenuously invoke freedom of speech to make the most outlandish claims, while simultaneously insisting that this right does not apply to those pointing out these claims are factually incorrect. One can only hope Libel Reform will be effectuated before more attempts are made to keep the public from knowing experts have debunked the medieval beliefs promoted by the anti-science brigade.

In the mean time, whenever you see an organisation/individual, engaged in making controversial claims, trying to limit the availability of information exposing possible misstatements on their part be very sceptical towards those claims. Especially regarding health related claims where they simultaneously, yet always coincidentally, sell something related to that "controversy."

Update: Then again, "I'll sue you" is so 1980's. To show your superior intellect in the 21st century you need to use a more sophisticated method of bullying, enter the Distributed Denial of Service Attack (DDoSA). Scienceblogs, a source of science information, is the latest to come under attack. Details by Greg Laden, Pharyngula, Aardvarchaeology, Orac, Mike the Mad Biologist.

The House of God

When I began as a resident I was allowed to ask for any diagnostic tool. The only requirement was that I needed to show the specialist I worked for how the results would influence my decisions. Imagine ordering an X-ray of the left foot to evaluate a possible heart attack. As it is impossible to make any reasonable connection between the two (foot-heart) no radiograph would be allowed.

Before that, as an intern, I was impressed to see an orthopaedic surgeon evaluate patients in order to find reasons not to operate. Later, as a resident I found that it is a trait seldom found among those trained to use a scalpel. The reasoning was, obviously, that we as physicians do cause complications, and as such may end up hurting patients.

With that in mind I just read an article, by Harriet Hall, which underscores that point:

We are healthier, but we are increasingly being told we are sick. We are labeled with diagnoses that may not mean anything to our health. People used to go to the doctor when they were sick, and diagnoses were based on symptoms. Today diagnoses are increasingly made on the basis of detected abnormalities in people who have no symptoms and might never have developed them. Overdiagnosis constitutes one of the biggest problems in modern medicine. Welch explains why and calls for a new paradigm to correct the problem.

To me, this is not rocket science. If anything, we were already warned by Samuel Shem that medical interventions inevitably introduce risks. His "good medical care is to do as much nothing as possible" I interpret to stand for:

1. There are so-called self-limiting conditions. This means they resolve by themselves without any treatment: i.e. common cold.
2. Medical interventions are inherently dangerous, there is always the risk it leads to complications.

These points should make any physician question the necessity of any intervention. The following examples are meant as illustration to those points, and of how I view diagnostic and therapeutic interventions.

One day a patient did not sufficiently produce urine. The medical history showed abdominal surgery the previous day, while the current status showed an i.v. drip with NaCl 1 liter/24h, an NSAID to counter the post-operative pain, blood tests suggesting deteriorating kidney function, and diuretics to correct for the diminishing urine production. At this time I was consulted to look at the kidney function. To the trained eye there already are several clues.

• Fluid replacement at 1 l/24 h is not much (the patient did not yet eat or drink), especially in abdominal surgery. This alone might cause dehydration. After evaluating the patient I concluded this was what happened,
• Of course, once a patient is dehydrated using diuretics appears somewhat counter productive: you need fluid to urinate, not lose more by stimulating diuresis,
• Then the use of NSAIDs, they are known to cause stomach, and kidney problems. In a patient that already has a compromised kidney function these drugs should be immediately discontinued, and replaced by another type of analgesic,

After concluding this was prerenal kidney failure, or dehydration, the fluid volume parenterally administered was increased to 2 l/24h, the NSAID and diuretic were stopped. Several hours later the urine production, and lab tests, returned to normal. This is not meant to embarrass any colleague but as a warning that something trivial as a painkiller may have devastating effects. In this case the patient might have ended up requiring haemodialysis.

An example of the risk diagnostic methods pose is perforating the colon, which is rare, when taking a specimen to evaluate polyps. To prevent you from falling asleep I will stop illustrating the point. You undoubtedly understand my point.

Thinking about these possibilities today my view is that we should always ask ourselves: is the possible complication from the therapy/diagnostic method I want to prescribe worth the expected benefit?

In short, is this test required for a diagnosis, and is non-treatment more dangerous than treatment? Only then should one proceed with the intended intervention. Or, "good medical care is to do as much nothing as possible."

As an aside, this maxim is applicable to other professions too.

BMJ: Wakefield is a fraud

In a stunning article in the British Medical Journal we are told that Andrew Wakefield, possibly the principal cause of the recent vaccines-are-evil-hype, is even less trustworthy than we discovered before.

Of course, who but Orac is on the prowl:

The discrepancies between the case reports as described in Wakefield's Lancet paper and the actual medical records are anything but random; all are in the direction of suggesting a link between the MMR and Wakefield's as yet unverified syndrome of regressive autism and enterocolitis. The cases that were selected appear not to have been random, sequential patients but were rather recruited specifically through anti-vaccine activists and trial lawyers.

And:

There is no innocent explanation possible for the systematic and numerous discrepancies between the medical record and Wakefield's paper, as the editors of the BMJ point out in their accompanying editorial:

The Office of Research Integrity in the United States defines fraud as fabrication, falsification, or plagiarism. Deer unearthed clear evidence of falsification. He found that not one of the 12 cases reported in the 1998 Lancet paper was free of misrepresentation or undisclosed alteration, and that in no single case could the medical records be fully reconciled with the descriptions, diagnoses, or histories published in the journal. 

Who perpetrated this fraud? There is no doubt that it was Wakefield. Is it possible that he was wrong, but not dishonest: that he was so incompetent that he was unable to fairly describe the project, or to report even one of the 12 children's cases accurately? No. A great deal of thought and effort must have gone into drafting the paper to achieve the results he wanted: the discrepancies all led in one direction; misreporting was gross.

Nevertheless:

Wakefield continues to deny that he has done anything at all wrong and blames the criticisms leveled against him on conspiracies. In reality, given the way the anti-vaccine movement has begun to circle the wagons to defend Wakefield yet again, it's tempting to claim that this is a conspiracy.

In his analysis Brian Deer likens this fraud in scope to Piltdown Man. The next commentator is Phil Plait who writes:

Brian Deer, an investigative journalist, has written a multi-part series on the BMJ site which slams Wakefield. Fiona Godlee, BMJ’s editor-in-chief, also writes about this… and just to be clear, she uses the word "fraud" nine times in her editorial. Not surprisingly, it’s been picked up by several news outlets like CNN, MSNBC, and ABC.

His conclusion:

Andrew Wakefield may not have started the antivax movement, but he certainly egged it on very strongly, along with such mouthpieces as Jenny McCarthy, and Meryl Dorey and the AVN in Australia. If the charges of fraud can be made to stick, then we might be able to make some progress toward reality once again, and lower the rate of outbreaks of measles, pertussis, and polio… and save a lot of lives in the process.

This is exactly why I am not opposed to accountability for willfully endangering other people by invoking free speech. More on the BMJ story by both Pharyngula, Deltoid, and Jeffrey H. Toney.

In the past I have wondered why people adhere to a worldview that has been thoroughly discredited. My unscientific opinion was that it must be some form of delusional disorder. Later, I noted the cognitive dissonance which has been shown to explain such behaviour. In light of what the BMJ has just made public one would hope the infectious-disease-promotion-movement will lose members. Unfortunately, being a cynic, I doubt that will happen.

Update: Be sure to read this too.

Update II: A roundup of responses to the BMJ article is provided by Liz Ditz. The Autism Blog discusses the alleged replication of Wakefield's results: it does not exist. In Scientific American David Ropeik explains that there is a discrepancy between the perceived and factual risk:

Sometimes we’re more afraid than the facts say we need to be (vaccines). With many of the bigger threats, we’re not afraid enough (infectious disease). The gap between our fears and the facts can be dangerous all by itself. Just ask the parents of the thousands of kids worldwide now getting, or dying of diseases that vaccines had pretty much controlled.

And:

The harm he [Wakefield] and others have done will persist for a long time…and will continue to serve as a reminder of the risk we face if we don’t recognize that the way we perceive risk can be a huge risk in and of itself.

The danger of the infectious-disease-promotion-movement is shown by Maryn McKenna who contracted whooping cough in India and wrote an article in Wired about the rise in cases. Take home message:

The worst news in this upsetting trend is this: We’re doing it to ourselves. As far as anyone can tell, the rise in pertussis is not due to any change in the organism, or to any mysterious error among the manufacturers who make pertussis vaccines. It’s due to vaccine refusal, to parents turning away from vaccines because they think the vaccines are more harmful than the diseases they prevent — or, more selfishly, because they think the wall of immunity created by other vaccinated children will protect their unimmunized ones.

Grant Jacobs, for Code for Life, made an overview, and Skepacabra did the same. Nice review of communication pitfalls by The Thoughtful Animal:

Giving us incidence and death rates and other such statistics doesn't really get the job done. It doesn't communicate what they want it to. Nor will glossy pamphlets (like the one they gave me) featuring Mia Hamm telling us to get vaccinated. What will get the job done is story-telling, appealing to emotion, and utilizing accessible analogies. Instead of telling us how many gazillions died last year, tell us how many airplanes full of people, or how many football stadiums full of people died last year.

Update III: Luckily Jenny McCarthy comes to our recsue and rehashes long ago refuted non-arguments. Apparently, true or false is determined by the number of times you make a claim.

Thou shalt be "Fair and Balanced"

One of the reasons I am utterly unimpressed by journalists is their strict adherence to the "present-both-sides-equally"-doctrine. They have convinced themselves that to be neutral, objective or whatever a "good reporter" is supposed to do, one should always give equal time to opposing voices. Especially, when there is no serious debate among experts. In short, if science says HIV causes AIDS your duty as a journalist is to include somebody asserting this is not true. Not only that, but to give both views equal weight. The same principle holds true for Holocaust denialists, Flat earthers, the infectious-disease-promotion-movement, et cetera.

Then, an article appeared in the Chicago Tribune that dismissed the validity of claims there is such a thing as Chronic Lyme Disease (CLD) by presenting the current scientific consensus which refutes that notion, and as such evades the "mislead-your-audience-at-all-costs"-doctrine. Because of the quality of their reporting PalMD notes:

It starts with a piece in the Chicago Tribune by Patricia Callahan and Trine Tsouderos.  The award winning pair have been among the few reporters to consistently “get it right” about alternative medicine. Tsouderos is well-respected among critics of quackery for her willingness to look at the science and report the truth, without resorting to false balance*.  Callahan and Tsouderos’ investigation into the dangerous and deceptive practices of alternative autism doctors, practices that include chemical castration, won cheers from those  screaming out against this unethical mistreatment of children.  These reporters have got the bona fides amongst both journalists and scientists.

Observing the article not using this doctrine, Orac writes:

One exception to this profoundly annoying pattern (if you're a skeptic) has been the journalism of Trine Tsouderos, who with Pat Callahan, has produced over the last year or two a number of excellent, science-based stories on the anti-vaccine and its associated "autism biomed" movements, including an expose of Boyd Haley's "rebranding" of an industrial chelator as an autism treatment. She's even taken on "America's doctor," Dr. Oz. As a result, she's been demonized by cranks, up to and including having her face crudely Photoshopped into a picture of a Thanksgiving feast in which she and various others whom the merry band of anti-vaccine loons at Age of Autism view as enemies were portrayed as sitting down to a meal of dead baby.

Astonishingly, this article is than attacked by Paul Raeburn, former senior editor for science at Business Week, former science editor at the Associated Press, author of three science books, and director of a university science journalism program, for ..... not adhering to the "Fair-and-Balanced"-principle. Quoth Orac:

Boiled down to its essence, Raeburn's complaint is the opposite of what we skeptics, scientists, and supporters of science-based medicine complain about all the time about journalists, namely that Callahan and Tsouderos did not fall into the trap of false balance, did not give undue credence to pseudoscience, and did not "tell both sides" as though they had equal or roughly equal credence.

An identical observation regarding the “lack of balance” can be found in PalMD's response:

When it comes to truth, it doesn’t matter how Paul Raeburn perceives the process.  A medical fact is a medical fact, and while he may not like the way they came to their conclusion, the truth remains. 

It does not matter which "controversy" you prefer, there will always be experts, and many more non-experts, that disagree with the consensus. However, a few lone wolves do not a scientific debate make! This is what any competent journalist should convey to his/her audience. As long as those journalists are insufficiently capable of drowning out the noise the general public can't help but be misinformed. At present it has become annoyingly clear that without this massive failure of journalism we would not have an organisation like Wikileaks.

Update: Corrected grammar in last sentence.

Update II: To prove my point Javier Moreno, for El Pais, observed:

As Simon Jenkins of The Guardian wrote earlier this month, power hates to see the truth exposed. I would add that above all, power fears the truth when the truth doesn't fit its needs. I knew immediately after I received the first call from Assange that Friday in late November that EL PAÍS had a great story on its hands, and that it was our duty to publish it.

But despite our concerns, there was something that all of us involved in the process never doubted for an instant: we had a responsibility to the democracies that we live in to publish the story. Revealing the truth is the touchstone of true journalism, and the reason we get out of bed in the morning.

And, as if he had read this blog, he denounces the meme I described before:

It is the prerogative of governments, not the press, to bury secrets for as long as they can, and I will not argue with this as long as it does not cover up deceitful acts against citizens. But a newspaper's main task is to publish news, and to seek out news where it can find it. As I said in a recent online chat with EL PAÍS readers, newspapers have many obligations in a democratic society: responsibility, truthfulness, balance and a commitment to citizens. Our obligations definitely do not, however, include protecting governments and the powerful in general from embarrassing revelations.

Update III: New post on our trustworthy media here.

Correcting "misinformation week"-week

The Ministry for the promotion of infectious diseases has anounced a “Vaccine Awareness Week” from november 1-6. To counter the spread of the denialism-virus by the we-need-no-stinkin'-science-crowd David Gorski has suggested an antidotum. As Steven Novella writes:

we will be posting science-based information about vaccines, and countering anti-vaccine misinformation throughout the week. Look for these posts on Respectful Insolence (Orac has also announced the event), here at NeuroLogica, and on Science-Based Medicine.

The team supporting science consists of the people at Science-Based Medicine and Neurologica, Orac, PalMD, Tod W., and Science Mom. If you are resistant to the denialism-virus because of a predilection for the scientific method you can follow their contributions through their pages or via Twitter using hastag #vaxfax. Naturally, should you be suffering from, and willing to be vaccinated (pun intended) against, the promote-ignorance-at-all-costs-virus you are more than welcome too.

Update: Other participants are Science-Based Pharmacy, and Scott Gavura, and Skepacabra. Seed Magazine offers an explanation as to why people are unwilling to vaccinate:

As Sam Harris argues in his new book The Moral Landscape, we have a bias against sins of commission rather than sins of omission.     

This means that the consequences of action are perceived as morally worse than those of inaction. Even if the result is the same. In the manufactroversy surounding vaccination

they see the government or meddling doctors causing autism—a sin of commission. But parents who don’t get their children vaccinated and end up causing a measles outbreak are only committing the lesser sin of omission.

Humans are also naturally biased to favor their own children over others’ kids, and to prioritize present dangers (like the growing autism crisis) over remote ones (like the dim memory of measles). Other biases may be in effect as well. Powerful biases such as these are difficult to overcome, but perhaps as we begin to see more and more potentially deadly outbreaks of preventable diseases, public opinion will change. Our attention to the question of autism might then be redirected towards research on effective treatments—but sadly, only at the cost of serious illness in children who might have been protected by vaccines.

While CNN reports on yet another victim, Matthew Lacek, of the infectious-disease-promotion-movement. And in 2008:

Measles—a highly contagious disease-causing virus—is making a comeback in the U.S., thanks to parents fears over vaccines. Fifteen children under 20, including four babies, have been hospitalized and 131 sickened by the red splotches since the beginning of this year in 15 states and the District of Columbia, according to the U.S. Centers for Disease Control.

According to Scientific American. But hey, we all know vaccines are evil.

Update II: The fruits of years of being educated by irrational fanatics, as CNN tells us:

Whooping cough, also known as pertussis, has claimed the 10th victim in California, in what health officials are calling the worst outbreak in 60 years.

Luckily, pertussis is not as dangerous as vaccinations are.

The infectious-disease-promotion-movement

Numerous blogs, this one included, have written about the pernicious effect Andrew Wakefield has had on vaccination levels in children. He singlehandedly was able to get nearly irradicated diseases reintroduced by claiming this highly effective method of preventing disease causes autism. This summer the infectious disease promotion movement suffered a setback when British General Medical Council (GMC) ruled against him. Since his adherents suffer from both a delusional disorder and the Dunning-Kruger effect, they may want to read about statistics in medicine, his downfall has not been the boost for vaccination rates less intellectually challenged people had hoped for. The legacy of his misbehaviour is a decreased herd immunity which still kills. Joseph Albietz remembers the death of a child:

He was unvaccinated, but that was because of his age.  He was part of the population that is fully dependent on herd immunity for protection, and that is exquisitely prone to a life-threatening course once infected.  

The failure of maintaining herd immunity makes him observe that:

the medical community in general is delusional if we think we can resolve the public health threat posed by the undercurrent of distrust in the vaccination program on our own.  No number of studies, consensus statements, or ad campaigns by the CDC, WHO, AAP, AAFP, etc (not to mention countless blog posts) will be sufficient to maintain the public trust in the vaccination program.  We need public support as well.

The Force remains strong in the anti-science camp. Luckily Penn & Teller offered us another solution by spending an episode of Bullshit on the subject. Orac reviewed it for us, and has the video. Yet another approach is suggested by Joseph Albietz:

In Atlanta, Georgia this September is a rather sizable (~40,000 people) convention called Dragon Con.  Our skeptic friends at Skepchick.org and the newly formed “Women Thinking Free Foundation” are launching their their “Hug Me! I’m Vaccinated” education campaign at Dragon*Con, and have organized a local pertussis vaccination clinic during the event.  In coordination with the local health officials, they are providing free TDaP vaccinations for any Dragon*Con participant, as well as information and educational materials.

But as long as airhead celebreties keep falling for the denialism-virus ....... Sigh.

Update: Another explanation for the importance of herd immunity is given by ERV.

Update II: The importance of herd immunity is surprisingly lost on the anti-vaccination crowd. The Watchdog Institute reports:

that waivers signed by parents who choose to exempt their children from immunizations for kindergarten enrollment have nearly quadrupled since 1990. California allows parents to opt out of some or all shots on the basis of personal beliefs, be it religious objections or distrust of the medical establishment.

This causes Orac to observe:

Failure to vaccinate also endangers the unvaccinated children as well. Last year, in fact, this risk was quantified in a study that found that unvaccinated children have a 23-fold elevated risk of catching pertussis compared with vaccinated children.

That is, if you accept what physicians say about herd immunity. We all know they don't know as much about diseases as the average celebrity.

Update III: What happens if others get infected because you object, for whatever reason, to vaccinations, i.e. you support the spread of infectious disease. The possible legal liability is discussed by attorney Jann Bellamy. The short version:

Those who breach their duty to avoid the spread of communicable disease may be liable to those injured for damages.

Update IV: If you still think the infection-promotion-movement is a harmless bunch of "sceptics" try reading about the harassment Amy Wallace was subjected to after writing an article called "An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All." Her experience with this witchhunt she explains here:

Autism’s False Prophets, Dr. Offit’s 2008 book, opened my eyes to the risks of reporting on vaccines. Before I began working on my Wired story I read it, focusing at first on his straightforward description of what being a vaccine advocate had cost him. He’d been vilified on the Internet as a profiteer, a prostitute who serviced Big Pharma, and worse. He’d been physically accosted. His life had been threatened. Once, an anonymous caller had even implied they might go after Offit’s two children.

What I experienced in the wake of my Wired story was similar in tone (although my child was spared). Like Offit, the vast majority of the feedback I received was positive, but the negative stuff would make your hair stand on end.

Despite all this she does not regret a thing:

My Wired piece was a chance to contribute in a meaningful way to a discussion that must be had.

She ends the article with some suggestions for those interested in promoting rational debate. Another article, by Shot of Prevention, also mention the Watchdog Instute's investigation and the effect of not vaccinating on herd immunity:

Perhaps more concerned parents should demand to know how many of their children’s classmates are coming to school unvaccinated.  As Dr. Mark Sawyer, pediatric infectious disease specialist at Rady Children’s Hospital in San Diego noted, “Un-immunized people in general contribute to any disease rates. As the rates of un-immunized kids go up, we are inevitably going to see more and more outbreaks of diseases.”  It is clear that a failure to vaccinate children attending school endangers us all.

Then there is the CDC which estimated the number of deaths due to influenza. I wish there was a way to prevent those infections.

Homeopathy in bad weather

As a result of recent findings that concluded homeopathy is nothing more than wishful thinking, otherwise known as placebo, Steven Novella reports:

Homeopathy is on the ropes in the UK. Earlier in the year The House of Commons Science and Technology Committee (STC) released a report, Evidence Check 2: Homeopathy, essentially saying that homeopathy is bunk and should no longer be supported. Recently representatives of the British Medical Association (BMA) condemned homeopathy as “witchcraft.”

And he continues:

Now the BMA is going one step further – calling for a ban on homeopathy in the UK. They do not want homeopathy to be illegal, but they want a ban on any National Health Service (NHS) support for homeopathy.

This, of course, is good news. Everybody should have the right to throw away his/her money by spending it on therapies that do not work. That proposition does not mean the rest of us should pay for their gullibility.

Update: According to Pharyngula there is a video that:

will hurt your brain, but don't worry, the pain will make you stronger. This is a mashup of a few homeopaths rationalizing their baloney, mixed in with Star Trek technobabble.

Then he comments on the above story:

There is a corrective: good news. British skeptics have been working hard to fight homeopathy, UK doctors have called for a ban on homeopathic 'medicines', and the doctors have voted to make homeopathy unsupported by the national health service! Reason triumphs for once!

 Sanity at last?

Homeopathy has not worked in 175 years

As anyone who subscribes to the scientific method knows homeopathy does not work. Interestingly Orac, while cleaning up his attic, discovered:

the oldest double-blind RCT of which I found record was conducted in 1835 in Nuremberg, Bavaria, and subsequently described in an editorial in 2006 entitled “Inventing the randomized double-blind trial: The Nuremberg salt test of 1835.”

It is not just today we have investigated and determined homeopathy is nothing more than wishful-thinking: that debate was settled 175 years ago! That is, to those that have not been infected with the denialist-virus.

Delusional disorder: Part II

In part I I outlined the tactics of the anti-science movement. In case you missed their various incarnations, I am talking about those denialists that claim that: the holocaust is just a PR-stunt, HIV does not cause AIDS, Global Warming is not happening, vaccines are the cause of everything evil, evolution is merely a theory, mobile phones cause cancer, terrorism is the biggest threat to your life, et cetera.

This time I want to try and understand why people are so resistent to facts contradicting their personal believesystem. The common thread of all "denialist controversies" is that no amount of evidence is sufficient to persuade denialists that they are simply wrong. This reminds me of what I was taught about the difference between an illusion and a delusion. When we have an illusion we see or hear things, but we are aware they are not actually there, i.e. illusionist, magician. A delusion, however, is seeing or hearing things without realising it is not there. No amount of evidence will convince people, suffering from a delusion, that it is imaginary, i.e. paranoid delusional disorder.

With this in mind I noticed the always invoked conpiracy -Big Pharma, Illuminati, Big Oil, et cetera- to explain away the multitude of scientific evidence refuting the denialist position. Add to that the Matrix-inspired notion that fact and fiction are essentially the same (i.e. evolution is merely one theory of many), together with the always present-both-sides-equally-fallacy invoking media, and science is guarenteed to lose.

Regardless of their idiosynchratic reality-refuting opinions the anti-science crowd shares some interesting characteristics. Skeptical Science noticed this too, and points out five characteristics of the anti-science disorder:

1. Conspiracy theories,
2. Fake experts,
3. Cherry picking,
4. Impossible expectations of what research can deliver,
5. Misrepresentation and logical fallacies.
   

Personally, I see the following traits among denialists:

1. Indoctrination,
2. Dogma supercedes evidence,
3. The denialist is always right, when he is proven wrong see point 2, 6 and 7,
4. Megalomania: the denialist is the only person capable of understanding/seeing The Truth,
5. Inconsistency: rigorously applying standards to others while failing to adhere to those standards themselves, see point 6,
6. Using invented facts, double-standard and logical fallacies,
7. Conspiracy theory: confronted with any evidence to the contrary it is dismissed as fake (scientists and industry work in unison to plant evidence to hide The Truth)
8. Cult-like behaviour (because of point 1)

Thinking of the DSM-IV one can't help but notice the similarity with the paranoid delusional disorder. The propensity to create elaborate explanations for ignoring/refuting what science says is the hallmark of delusional people. Since the "teach the controversy"-crowd has succeeded in removing critical thinking skills from schools' curricula and the media in their reports refuse to "take sides" we live in a world where fact and fiction have become equal.

Update: Kimball Atwood makes some suggestions regarding adherents of "alternative medicine," and wonders why:

some people are drawn to implausible treatments, even in the face of compelling, contradictory evidence. Such investigations might begin by looking at the work of Beyerstein and Alcock, for example.

Update II: Posted a more detailed explanation on the rationale behind the anti-science crowd. 

Statistics

Both in science, and legal proceedings, statitsics are used as part of the argument. But methamatics has shown to be more difficult and prone to misunderstandings. For an update on the ins and outs Steven Novella discusses the pitfalls in a review of an article by Tom Siegfried.

Update: Some additional points regarding randomized controlled clinical trials (RCT) by Andrew Gelman.

Update II: More from Open Mind explaining:

Statistics works, it does what it’s supposed to do. But it is susceptible to misinterpretation, to false results purely due to randomness, to bias, and of course to error.

Specifically:

One of the dangers inherent in statistical results is over-reliance on the “p-value.” The p-value is the probability of getting the observed result just by random accident, even when there’s no significant effect and the “null hypothesis”

All told, there are many ways for the statistical analysis of experiments to give incorrect results. This may be especially true in medical research, for which the financial incentive is high, the prior probability is often very low, and the sample size may be severely limited by circumstances beyond anyone’s control. But that hardly means that the foundation of statistical analysis is flimsy; that’s just sensationalism. Nor do we need to adhere to an impractically high standard of statistical significance — as desirable as it is, effects are often small and gathering more data (as in clinical trials) can be very expensive and time-consuming, while delays in availability of new treatments can be devastating for a patient with serious disease and few treatment options.

In addition to this explanation of statistics David Gorski and Kimball Atwood use the case of how the aetiology of peptic ulcer disease (PUD) was elucidated to illustrate how plausibility influences medical research. It might be argued that decades earlier than Barry Marshall and Robin Warren, John Lykoudis may have stumbled upon the same interpretation that bacteriae are involved. However, he did so based upon anecdotal evidence and without sufficient evidence to warrant dismissing the then current view that acid was the culprit. Gorski concludes:

I find Lykoudis’s story to be a cautionary tale. Whether he was correct and thus the true “Galileo” of H. pylori, rather than Warren and Marshall or whether he was just another crank, his story demonstrates that we scientists should be very careful to guard against excessive smugness. As has been repeated by many skeptics in many variants over the years, it is not sufficient to claim the mantle of Galileo as a persecuted martyr for science. You must also be right. Even though it is not clear whether, taken in the context of the time, Lykoudis was a crank or a misunderstood physician who was ahead of his time, Warren and Marshall’s vindication of his ideas that PUD is bacterial in etiology reminds us that not all who claim the mantle of Galileo are necessarily cranks. The vast majority usually are, but on very rare occasions we do see a real Galileo.

Another take on statistics can be found at Effect Measure. For the interested reader, and as a note to myself, some general information here, here, here, here.

Delusional disorder: Part I

So far, this year has been very good to those that support rationality and critical thinking. The anti-science crowd has suffered several setbacks in the past months. Mister vaccines-cause-autism, Andrew Wakefield, was exposed by the British General Medical Council (GMC) as "dishonest," "misleading" and "irresponsible," which resulted in the Lancet retracting his 1998 article which sparked more than a decade of fears for vaccination. Then, according to JURIST:

Three special masters sitting in the US Federal Court of Claims [official website] Friday rejected [opinions, PDF] three compensation actions brought in a coordinated omnibus proceeding [backgrounder, PDF; HRSA backgrounder] by families of autistic children who had argued that their children's autism was induced by vaccines containing mercury-laden thimerosol. The families had sought compensation under the no-fault National Vaccine Injury Compensation Program [HRSA backgrounder]. Special Master Patricia Campbell-Smith wrote that her petitioners had not "presented a scientifically sound theory", citing evidence that it was "biologically implausible." In February special masters in the same court rejected arguments [JURIST report] made in three other test cases against the US Department of Health and Human Services by families alleging that their children's autism was caused by a combination of common childhood vaccines.

Responding to the case Steven Novella observes:

This was a huge blow to the anti-vaccine crowd, and an excellent victory for science and reason. It was the equivalent of the Kitzmiller vs Dover trial for Intelligent Design.

His conclusion is:

This most recent decision by the Autism Omnibus is a slam dunk – after an exhaustive review of the evidence, allowing both sides to present their best case, the three masters are unanimous in their strong opinion that there is no evidence linking thimerosal to autism. They trashed every claim and argument brought forward by the petitioners – the logic and evidence simply does not support their case.

Normally, the fact that a major medical journal retracts the study that launched the infectious-disease-promoting-movement, combined with study after study refuting a reality denying view resulting in a verdict which emphasises the unscientific nature of the claims, one would think his supporters would re-evaluate their view and conclude it might not be compatible with reality. Not the anti-science crowd. Reminiscent of Hydra they are impossible to defeat. The loss of Wakefield inevitably results in a flood of ad hominems and attempts to discredit a real scientific study, through misrepresentations of how science works.

They focus on studies disproving a link between vaccines and autism. One of its authors, Paul Thorsen, allegedly committed a crime. The alternate reality inhabitants are oblivious to the inherent irony invoking his possible character flaw as evidence to invalidate scientific studies he participated in while ignoring the possible fraud by their Lord and Master. What they missed, according to Orac, regarding the irrelevancy of what a scientist does in his private life, is relevant how?:

Was there an allegation that somehow this alleged financial fraud had anything whatsoever to do with the design or excecution of Danish studies that failed to find a link between either MMR or thimerosal-containing vaccines and autism? Is there any evidence anywhere that Poul Thorsen committed scientific misconduct on the order of what Andrew Wakefield did? Seriously. I don't see anything in any of the number of vicious attacks on Poul Thorsen (who may or may not be a criminal), the SSI (which doesn't deserve them), or Aarhus University in Denmark (which also doesn't deserve them). It's a pure smear against these latter two institutions, guilt by association.
In other words, it's very typical of the anti-vaccine movement. The bottom line is that this is not a scientific scandal. It is a financial scandal that happens to involve a scientist.

In short:

1. He is not the main author,
2. Taking out one study does not negate the multitude of other studies showing the same thing: autism is not caused by vaccination,

But then again, when your belief is the sole arbiter of your worldview you are not interested in testing that premise. Rational people have an opinion based on the facts, while the anti-science crowd feels that the facts have to be adjusted to support their opinion.

Homeopathy = placebo

As long as I can remember I have had an open mind for the unusual and still I believe thinking outside the box is mandatory for anyone with the slightest interest in science. As an aside, as a doctor working in the Intensive Care Unit, or confronted with patients that have significant comorbidity, I occasionally need to find an alternative approach as the usual treatment is either insufficient, or too dangerous for the patient. I'll spare you the details. The point is I subscribe to having an open mind.

All this is a somewhat complicated introduction to a form of "alternative medicine" I feel requires a mind so open the skull has disappeared and the brain is lying on the floor. Not only does it violate the notion that when you make a scientific claim it has to have some plausibility, but every inquiry into its efficacy has shown it does not rise above the placebo-effect. You may know it under its awe-inspiring name: homeopathy.

Finally the Science and Technology Select Committee, in the UK, concluded:

By providing homeopathy on the NHS and allowing MHRA licensing of products which subsequently appear on pharmacy shelves, the Government runs the risk of endorsing homeopathy as an efficacious system of medicine. To maintain patient trust, choice and safety, the Government should not endorse the use of placebo treatments, including homeopathy. Homeopathy should not be funded on the NHS and the MHRA should stop licensing homeopathic products.(h/t Orac)

In The Guardian, Martin Robbins from The Lay Scientist, responds to their verdict:

Sadly, the criticism is likely to fall on deaf ears. Rather than take the opportunity to reassess their approach, homeopaths are filling blogs and tweets with dark imaginings of vast, Big Pharma-controlled conspiracies against their noble art, painting a vivid picture of the fantasy world that they appear to inhabit.

Steven Novella noticed the same ruling and commented:

The committee listened to proponents and critics, and found that homeopathy proponents cherry picked out-dated and fatally flawed studies to support their position, including a lecture series that wasn’t even a systematic review. Meanwhile, the best reviews of the best evidence clearly show that homeopathy is no better than placebo – which means it doesn’t work.

In another post Novella documents, this and other signs, that appreciation of science is awaking, which seriously damages the anti-science movement. Coincidentally this blast from the past at Bad Science.

In case you are still wondering: how does it work?

Now it is official. The purveyors of anti-science have discovered the newest incarnation of the placebo. What may it be you ask, quoth Orac:

Why homeopuncture, of course:

There is always a new non-therapy (a.k.a. placebo) to promote. Sigh.

Animal rights

This is episode 307 from the series never let science interfere with ideology which deals with the Animal Rights Movement. These idealists proclaim to save animal life by correcting the falsehood that experiments on animals are essential to understanding diseases and developing medical treatment.

Leave it to Orac to correct the misleading, if not severly reality-denying, statements. He concludes his article with the following:

Just remember, whenever you hear seemingly "scientific" arguments against animal research that emphasize how bad and inaccurate it is, ask for concrete examples from the peer-reviewed literature that show that non-animal modalities are consistently equal to or better than animal experiments to answer the question being asked. You'll be hard-pressed to find them.

But then again, since when do we need science to influence our views?

If science fails you resort to old-fashioned bullying

In the past I have written about the tendency of the scientifically challenged to stifle debate through legal threats. The virus is spreading. Now we have yet another case of criticism, this time about Christopher Maloney, that is disallowed. PZ Myers identifies the genius behind this attempt at censorship:

The Prime Quack has been identified: Andreas Moritz. He has admitted to getting Wordpress to pull Michael Hawkins' blog, and is also threatening me, now.

Here is the way Orac feels about this nonsense.

Seemingly, whenever a quack or a crank encounters serious criticism, the first reaction is almost never to try to argue based on facts, reason, and science, but rather to try to silence the person doing the criticizing. The tactics are many and varied, but the end goal is always the same: Suppress the criticism by any means necessary.

He goes on to list several examples from his own experience to illustrate the point.

Update: Skeptico has discovered this "debating technique" too.

Update II: Apparently WordPress has decided to allow valid criticism once more and the original blog is up and running again. In a new post Michael Hawkins thanks all those that put pressure on WP.

Wakefield leaves Thoughtful House

It appears that following the removal of what was left of his authority, within the scientific community, Wakefield is no longer part of the money making machine called Thoughtful House. Trust Orac to speculate on the reasons behind this move.

The Vaccine Illuminati

It appears the "Vaccine Illuminati" have intervened to stop The Truth from being told. Jenny McCarthy and Jim Carrey, eternal inspiration to the infectious disease promotion movement, have reacted to that vile act of ruling against Andrew Wakefield, and retracting his unscientific article. Orac discusses, and disects, in detail the merites behind their logic and exposes them as fearmongering conspiracy loons.

Update: Of course, they conspicuously ignore those that have died as a result of their appeal to emotion.

Update II: Aggregate of links to the retraction here.

Chris Mooney: Science has to be more unscientific

Chris Mooney, after failing to lower the heat in other topics of science, has proposed his solution to all "controversies." Scientists should play nice and stop invoking facts and reason when confronted with the infectious disease promotion movement. Weird Things notes:

Previously, he’s done this with the evolution/creationism manufactroversy and scientific literacy. Now, after managing not to resolve either problem and missing the fact that blaming scientists for a culture which rejects science and expertise as a manifestation of elitist snobbery doesn’t actually accomplish anything, he’s off to make friends with the anti- vaxers and implore doctors and epidemiologists to build bridges with zealots who demonize their critics as baby-eating monsters.

He concludes:

His suggestions for all those involved in a big public dustup over science to sit around a campfire and sing Kumbaya, are born from a lack of consideration for the psychology of both sides and the environment from which they come, and if they really worked, he wouldn’t even have to write about militant anti-vaxers and creationists in the first place.

Regarding this way of thinking Orac points out that Mooney:

appears utterly unaware that scientists have been trying to reach out and build bridges to leaders of the anti-vaccine movement for years, if not decades. It hasn't worked. It doesn't work. As Mike Stanton pointed out in a comment, public health bodies courted Barbara Loe Fisher of the National Vaccine Information Center (whom I've discussed recently here, here, and here). The only result is that it raised her profile. She hasn't budged an inch; she is still as anti-vaccine as ever. One recent example that stands out in my mind occurred in 2007, when Sallie Bernard of SafeMinds participated as a consultant in the design of a large study designed to ask whether there was a link between thimerosal containing vaccines and neurodevelopmental disorders other than autism. Unfortunately for her, the study failed to find a link. All investigators found were a handful of correlations, both positive and negative, that occurred at a frequency consistent with random chance. In a case of sour grapes, Bernard disowned the study before it was published and then, after it was published, launched attacks against it, even going so far as to write a letter to the New England Journal of Medicine criticizing it.

So, countering a misinformatiion campaign by sitting round a campfire, and holding hands, is the last we need to do. "Every attempt to do so is viewed by them as a sign of weakness or vindication of their crank views, never as an opportunity for compromise." Therefore, science should simply continue to call out the factual errors, and well-known lies, the anti-science groups use to spread their cult. We don't debate the shape of the earth, the aetiology of AIDS, whether our neighbour is in league with Satan, et cetera, either.

Evidence-Based Medicine vs. Science-Based Medicine

The medical profession has adopted Evidence Based Medicine (EBM), and its use of Randomized Controlled Ttrials (RCT's), as principal method to use when looking for the best way to diagnose and treat a certain disorder. Kimball Atwood, for Science-Based Medicine, points out that

several of us [at Science-Based Medicine] consider EBM to be incomplete in its gathering of evidence 

He also observes

that human RCTs, as good as they are at minimizing bias or chance deviations from population parameters, cannot ever be expected to provide, by themselves, objective measures of truth. There is still ample room for erroneous conclusions. Without using broader knowledge (science) to guide our thinking, we will plunge headlong into a thicket of errors—exactly as happened in parapsychology for decades and is now being repeated by its offspring, “CAM” research.

In his view EBM, at present, is a "subset of Science-Based Medicine (SBM), because EBM by itself is incomplete." When it incorporates all the evidence EBM and SBM will be "interchangeable."

Update: Evidence in Medicine discusses EBM and its limitations too.

Surprise: Dr. Wakefield 'abused position of trust'

The Independent reports on the General Medical Council (GMC) hearing, regarding Andrew Wakefield, which observed his:

conduct brought the medical profession "into disrepute" after he took blood samples from youngsters at his son's birthday party in return for payments of £5.

And it found that he:

"failed in his duties as a responsible consultant" and went against the interests of children in his care in conducting research. He further acted dishonestly and was misleading and irresponsible in the way he described a study which was later published in The Lancet medical journal.

This article claimed a relationship between MMR vaccination, bowel disease and autism, and became the cornerstone of the "infectious disease promotion movement." The Times notes that this study

sparked the biggest vaccine scare in a generation and has been blamed for the resurgence of measles in Britain.

Subsequent investigations repeatedly established its unscientific nature, confirmed by the GMC today, and medical science has refuted those proposed links as non-existent. The Times describes the ensuing debate following the article:

The research has since been discredited by subsequent studies involving millions of children, which found no evidence for the link between the triple jab and autism. It has since been retracted by the Lancet, and ten of the original 13 authors disowned the research. But the claims sparked a massive drop in the number of children given the triple jab for measles, mumps and rubella. Vaccination rates have still not fully recovered to levels before the scare.

The Guardian discusses the same ruling, and Steven Novella has an elaborate overview of who Wakefield is and what he has accomplished.

Update: A somewhat superfluous, to those following the "infectious disease promotion movement," rersponse is given by Orac who describes Wakefield's legacy as:

The resurgence of a once-defeated vaccine-preventable disease, with all the attendant suffering its return brought with it. Truly, few people can be said to have done more harm to public health in a nation than Andrew Wakefield did in the U.K. with his incompetent, unethical, callous research.

The post is a detailed review of the ruling and includes the delusional, and inherently cult-like anti-science, platitudes his defenders use to prove the GMC's conclusions were nothing less than blasphemy. Of course, this difference of opinion is best explained by Tim Minchin:

Science adjusts it’s beliefs based on what’s observed
Faith is the denial of observation so that Belief can be preserved.

The Lay Scientist, Science-Based Medicine, and Skeptico also comment on the outcome of this science vs. Paranoid R Us spectacle.

Update II: A very unusual decision has led The Lancet to retract the original article. Steven Novella details the high threshhold journals have for retracting articles such as this. Even when it is obvious fraud is involved.

Update III: Oddly enough the Paranoid R Us Crowd -while claiming "The Censorship of Autism Treatment"-is objecting to the scientific principle, rational thought, and plain decency by asking us to support poor persecuted Mr. Wakefield.

Update IV: More from Orac and The Globe and Mail.

Update V: ABC has a big article too.

Update VI: More here.