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Evidence Based Medicine? We Don’t Need No Stinking Evidence Based Medicine
March 20, 2008 | Leave a Comment
The Free Netter’s Ain’t Worth It
I am an educated man. I have an extensive liberal education, a degree in Civil Engineering, a Medical Degree, and am almost done with residency training in Emergency Medicine. Just for fun, I read the kinds of books they forced you to read in your long-forgotten English literature course (not that you actually read them but instead passed the course with the help of CliffsNotes and the professor’s fear of damaging your ego). While not an expert in much, I have a good working knowledge of physics, biology, chemistry and enough of the medical sciences where I at least know enough to understand new concepts as they present themselves and when smoke is being blown up my ass.
On the other hand I am also an ordinary guy and have done my share of regular jobs from fast food to landscaping and a lot of things in between. As I may have mentioned once or twice, I was also a United States Marine Infantryman and consequently know which is the dangerous end of a gun and, while I am today just a stocky suburban dad, at one time could and did endure physical hardships that would make the typical malignant Attending Physician, cock-of-the-walk in the hospital chicken house, weep like a little girl.
I have by no means seen and done it all but I have a pretty good idea how things work. I confess, however, that about one of the major underpinnings of the great structure that supports my beliefs, I have been wrong. Completely and utterly mistaken, so much so that if I could, I would find everyone upon whom I inflicted my totally incorrect theory and humbly abase myself in abject and total apology.
You see, for my whole life I have believed, and defended vigorously, the notion that being educated does not preclude one from having common sense. The conventional wisdom is the contrary of course, and I have heard this wisdom expressed often, especially when I was a Marine. “Yeah, he’s book smart,” went the typical conversation, “But that guy can’t find his ass with two hands and a flashlight…couldn’t pour water from his boot if the instructions were on the heel.”
I’m not saying that educated people are immune from stupidity, just that education does not cause stupidity and I have been a champion, a lion, in the defense of education as a complement and even an enabler of common sense. After all, many of the cool kids at my high school who eschewed the Chess Club are currently living in single wide trailers with women who, despite weighing 400 pounds (181 kg), are still trying to cram themselves into the same revealing clothes they wore in their brief flowering of trailer park beauty, those precious couple of years as fleeting as the tundra blossoms, between their first tattoo and their first illegitimate baby.
And then I read, via Orac at Respectful Insolence, about something called the Complementary and Alternative Medicine Leadership Program, sponsored not by some third rate chiropratic mill but by the American Medical Student Association, a splinter group of the august American Medical Association, who have bribed hundreds of thousands of medical students to join their ridiculous organization by giving them a free anatomy atlas (Netter’s).
I wept.
Suddenly, what I once thought to be the stable soil underneath the foundations of my weltanschauung heaved as if nothing more substantial than wet gumbo clay. Maybe smart people are prone to be booger-eating morons after all. I mean, seriously, here’s a group of American medical students who they tell me are drawn from the very top percentiles for intelligence spending their summer sitting at the feet of homeopaths, acupuncturists, and Reiki healers, soaking up the woo like so many lumps of dry cornbread. And they are buying it. Completely and wholeheartedly. The natural skepticism which is the true birthright of an educated man seems to have skipped a generation.
Take something like Reiki, one of the latest and trendiest of the new age Complementary and Alternative Medicine therapies. The Reiki practitioner claims to produce medically significant effects on a patient by shooting sacred fire out of his appendages. That’s it. That’s all there is to it. Once you strip away the Eastern mysticism and flamboyant Asian ambience it’s just a guy shooting spiritual energy into a patient. I told my Heating and Air Conditioning Guy about Reiki and he laughed.
“Hey, maybe you can get a a Reiki healer to shoot some mystical fire out of his ass to fix your furnace,” he said, “But in the meantime I’m still going to have to charge you a hundred and twenty bucks for the new igniter.”
The Good Lord knows that I embrace the concept of Evidence Based Medicine. A lot of what we do in medicine is marginally effective (if at all) and it is sometimes only tradition and a general sense that something should work (even if it doesn’t) that keeps us doing it. Evidenced Based Medicine is a world-view, a system of thought, that allows us to test everything we possibly can and eliminate these therapies that are ineffective or even harmful. But Reiki? With respect to my colleagues investigating every aspect of medicine, I don’t need a double-blinded placebo controlled study, a meta-analysis, or any other proof except the obvious one that some smarmy guy with a mail-order degree in Eastern mysticism cannot shoot spiritual fire out of his hands. First because there is no such thing as spiritual fire and second because, well, he’s some smarmy little fraud with a mail order degree. As I mentioned in another post, res ipsa loquitor; some things just speak for themselves and while I appreciate the zeal of many in the scientific community to test even things that are obviously ridiculous on a fourth grade biology level, I don’t necessarily need a lot of evidence to suggest that magic fairies and pixie dust are not legitimate treatment modalities.
Which is kind of the point of research into things like Reiki and Homeopathy. What on Earth do you expect to find? Even those who are inclined to believe in this kind of nonsense, when pressed, will admit that for any given Complementary and Alternative Medicine therapy the research is generally incredibly shoddy and, even allowing for a generous confidence interval, a blind eye turned towards the biases of the researchers, charitable peer review, publication in journals that are only one step above the supermarket checkout line variety, a favorable wind, planetary alignment, and an early showing by the groundhog, the positive results are slim, barely detectable, and easily ascribed to a placebo effect; something that is controlled for in real medical research and, if detected taints the entire study. In the world of real medical research, you understand, discovering that your prized medication is no better than a placebo is not greeted with war whoops and fists clenched in triumph.
No high fives, in other words. Back to the old drawing board. Things work the other way in the mystical world of Complementary and Alternative Medicine. The discovery of some insignificant statistical anomaly in a poorly designed and non-reproducible study is greeted with the same enthusiasm by the true believers as the discovery of the structure of DNA and we must now run, not walk, to legitimize their particular brand of fairy dust and use it on everybody. Pulling the same trick in real medicine leads to eventual exposure, embarrassment, ridicule, and even criminal charges. While every medical therapy involves some combination of cost and effectiveness, for Complementary and Alternative Medicine the cost (because Reiki healers do not dispense spiritual energy for free) is not even remotely worth whatever miniscule and highly subjective clinical results can be delivered by what is essentially an entertainment modality and not a medical one. You could, for example probably get the same results watching old Kung Fu reruns as you could with acupuncture. Or, to put it another way, acupuncture won’t work if it’s some bored acupuncture tech named Frank doing it, even if he puts the needles in the right spots. Unless he dazzles you with his mystical dog-and-pony show it’s just some paunchy guy smelling of cheap cologne sticking needles in you.
You know, I cannot help but sympathize with the young AMSA scholars. Medical students are not generally the popular kids in high school or college. The demands of making good grades and navigating the poodle-circus of medical school admissions preclude a normal social life. For my part, I was something of a nerd in high school. I was on the Debate Team, for Mohammed’s sake. Can’t get more uncool than that so I understand full well the appeal to you, oh young AMSA scholar, of going to some retreat with a group of your geeky friends lead by a bunch of people who, as you are the future leaders of medicine, will coddle, stroke, and reaffirm how special you are. It probably gives you the same rush you got from representing Cuba in the Model United Nations. But that’s the thing, isn’t it? Complementary and Alternative Medicine at the medical student level is not about the patient but about the medical student who use it as a positive affirmation of their own values; their open-mindedness and their unshakable belief that some Native American Medicine Man chanting around a sacred fire has something legitimate to teach the medical profession. It’s a way to resist the brutal self-discipline required to put away the fantasies of childhood and deal with the World-As-It-Is rather than how you would like it to be.
It also affords you the opportunity to get close to that awkward but reasonably pretty girl who otherwise won’t give you the time of day but who sent shivers up your spine that time she accidentally brushed by you. Dude, that’s why they have Spring Break. Not that I don’t applaud your motivation, especially if you are into earnest chicks who want to save the world but just admit it and stop with the magic fairies.
Housekeeping Stuff:
1. Congratulations to Graham over at Over!My!Med!Body! for matching into Emergency Medicine. Welcome to the club and no matter what they say, all the other specialists secretly wish that they were the combination of poker player, cowboy, daredevil, scholar, and circus clown that it takes to be an Emergency Physician. I can’t imagine doing any other specialty (even though anesthesiology looked mighty good, details in a later post, when I recently did a two week rotation) and once you get through all of the intern year crap you will enjoy yourself immensely.
2. Your comments are appreciated. Please, limit your links to two (2) as my spam filter is on a hair-trigger. No matter what your comment-the cardioselectivity of various drugs, your groundbreaking economic theories-if you use the words Brittney or Spears anywhere in the comment I think it is automatically shredded.
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