Ok guys, I was hoping to have fully researched answers tonight. Sadly our library was closed and I couldn’t access the appropriate references. I’ll just try and update this with references tomorrow. Below is the brief rundown, sans the numbers.
Archive for the ‘Science Based Medicine’ category
We’ve been talking a bit about evidence based medicine here at Beyond the Short Coat. In the Hard Conversation posts (1, 2, 3, 4, guidelines here), we’ve noticed a lot of dissenters bring up alternative treatments. Invariably, these treatments aren’t evidence based, and don’t work. They generally are “treatments” that seem to be “safe”, but often have no basic science basis. The classic example is homeopathic treatments – which are generally just sugar water. Sometimes people bring up more controversial, less benign things – chelation therapy comes to mind.
So why in the world would people use a treatment like that? Classically we talk about placebo effect: some people improve if you just tell them you’re giving them strong medicine. Occasionally I bring up the fact that complicated diseases have variable courses. That’s not the whole story though, and in this paper Tanaka, Kendal, and Laland, show us another side of the issue.
The authors created a simple mathematical model to simulate the spread of possible treatments in a population. This isn’t a model of doctor dispensed or recommended treatments. This model is specifically about “self medicating” – more similar to over the counter meds, and traditional therapies, things with a pretty low barrier to access. They start out with a population, everyone is either sick (“diseased state”), or healthy(“healthy state”). People who are healthy can become sick and people who are sick can become healthy. Then they introduce a “treatment”. This treatment can either be adaptive (it works), neutral (it doesn’t work), or maladaptive (it makes things worse).
They assume that sick people will expose others to this treatment, and that people adopt the treatment at a constant rate of the time they “see” the treatment. Notice, I said nothing about the treatment working or not. The authors assumed people had no way of telling if a treatment works or not. Don’t be insulted, it’s a pretty reasonable assumption. In fact that’s the reason we have to do evidence based medicine – people generally can’t tell if something actually worked, or if they just got better anyway. They also assume that the longer a treatment doesn’t work, the more likely a sick person is to abandon the treatment.
This model in hand, the authors can ask a lot of questions. They can test a variety of situations. What if the disease is short lived, and rapidly gets better on its own? What if it never gets better? How about if people can catch the disease multiple times? What if the treatment works really well? What if it makes things worse? What if people only expose others to the treatment when they’re sick? What if they expose others to the treatment forever? How fast do people abandon a treatment that doesn’t work?
Their results are interesting to say the least. By their model If people can only get the disease once, the disease is relatively short lived, and only show people the treatment to others when sick, then treatments that don’t work, or hurt you, spread better than effective treatments! Why? Bad treatments give longer “exposure times”, which lets more people pick up on the treatment.
Now if you flip it – if the disease is long lived, and if people spread treatments all the time instead of just when sick, this model tends to select effective treatments as more dominant.
If you can get sick more than once – that too trends towards effective treatments over the long haul.
Interestingly, their model shows that prophylactic treatments spread badly, because they don’t offer a lot of opportunity to get “converts.”
So how much stock can we put in this model? How closely does it resemble real life? Across the board, it’s limited. Not enough of medicine fits in with their initial assumptions. While they discuss CAM in the paper, this model seems to resemble a lower tech, more “traditional medicine” approach. So it may model the spread of modalities in the past better than in the age of the internet.
One situation that does seem to work is flu season – it’s an illness that resolves quickly, and generally the flu “cures” are only used when you have the flu. Admittedly, one can get the flu every year since there are different strains every year. The situation fits the model pretty well actually – there are all manner of non-efficacious flu treatments out there!
How about our topic of choice recently – vaccines? Vaccines are generally pretty easy to come by – yes technically a doctor should be involved, but outreach is pretty high, and the barrier to vaccination is low. It’s a prophylactic treatment, so once you’ve gotten vaccinated you aren’t showing the whole world the joy of vaccination while you’re sick – because you don’t get sick! Well that actually fits the model pretty well, we have to do all kinds of things to get people vaccinated, and it’s not easy!
Where does this model breakdown? The easy one is chronic disease. This model predicts that long duration of disease leans away from bad treatments. Yet those patients who have chronic diseases will often try a wide variety of non-efficacious treatments. I think the inherent assumptions don’t fit chronic disease well though. In chronic disease, rather than pick therapies based on time exposure, one is more likely to actively seek out therapies. Additionally I think there are psychological components that are a little too subtle for this model to take into account.
One obvious issue is that this model doesn’t take into account the ways doctors can spread good practices. Nor does it give us a model through which other “thought leaders” can spread practices. I’m thinking of course of the celebrities – Like She Who Shall Not Be Named of the vaccine denialists. These are powerful forces today.
I think this model is an interesting counterpoint to our regular ongoing discussion here. Regularly commenters bring up “treatments” that have “helped children recover”, in an effort to spread their particular brand of “medicine”. They never cite evidence, they never see the need for it. I find it comforting to think that a model assuming patients know nothing about treatments can lead to this behavior. In my mind that means that maybe, just maybe, science based medicine can make a dent in this situation through the appropriate education.
Tanaka, M., Kendal, J., & Laland, K. (2009). From Traditional Medicine to Witchcraft: Why Medical Treatments Are Not Always Efficacious PLoS ONE, 4 (4) DOI: 10.1371/journal.pone.0005192
Before I disappear for the holiday weekend, I wanted to put out one last post.
Firstly, go check out Science Based Medicine – a blog about the battle against pseudoscience. Go check it out! I’ll wait right here. I promise it’s relevant to the rest of this post.
Secondly, through the short lifetime of this blog my goal has been to educate people about science and evidence based medicine. This has proved more difficult than I initially hoped.
In my initial posts I at least try to keep the language understandable to the generic educated lay person. Sadly by about comment 3, a pseudoscience advocate cites 3-10 articles that they don’t understand, or that are thoroughly out of date. Then by comment 10, multiple scientists have appropriately responded, but the thread is no longer in reach for the very people I was hoping to reach with this blog.
Unfortunately, journal articles are just as easy to manipulate into pseudoscience as any other resource. Google-fu now makes it easy to put multiple citations and some 10 dollar words between a loving family and the appropriate evidence.
I’m going to try to make some changes going forward to make this blog still more accessible, and hopefully keep the discussion more relevant and understandable. Unfortunately, to do so I’m having to make some hard decisions. I banned my first poster last night, which greatly disappointed me. I was hoping by keeping a respectful tone I’d be able to have an open engaging discussion with both sides of the aisle.
I was warned before I started that affording respect to those who will abuse it would burn me. Some sites don’t have this problem – without the courteous tone I’ve encouraged, it’s very easy to burn the pseudo-scientific offenders out. Sadly, until now it’s been very easy for someone to just keep citing random articles and throw out a few “I don’t understand”‘s to sound reasonable enough, yet derail any progress.
Now after the holiday weekend – I’ll be swearing off the Internet from when this post comes up on line until Monday – I will post updated guidelines for the Hard Conversations series, and for this posting on this blog in general. I’ll continue to be soft on patients, but I will be much Harder on Woo. I apologize if that makes this blog feel less open, less free of speech, but I now think it’s necessary to ensure we are not hijacked by the unscrupulous minions of ignorance.
So how does this connect to the Science Based Medicine blog? The post series in particular is by the wonderful Kimball Atwood, “Harvard Medical School: Veritas for Sale” . I have linked to the first post in that series. It may not be entirely appropriate reading for one segment of my audience – the parents/patients among you will find it dry. The scientists and doctors may find it an entertaining, and disturbing look at the big business of medicine. I find this relevant because if Harvard can’t get it’s business in order on science based medicine, how in the world can you?!
The reality is that, it’s a complicated task to keep up with what is science and what is pseudoscience. I will endeavour to cover and explain science based medicine to the best of my ability. Please continue to let me know where I can improve guys, I really appreciate your input.
For now, enjoy!