Saturday, July 9, 2011

Journey into skepticism

I discovered science as a primary school child. I was fascinated by the chemistry, physics and biology books and encyclopaedias that my parents had bought my older brothers. The discovery of the public library and realising that I could borrow books other than The Famous Five and The Secret Seven meant that I could explore science further, so that when I started studying science in school, I just lapped it up. It was a natural progression through science into medicine. Starting medical school in 1980, I underwent what was then the traditional format of medical teaching, with separate pre-clinical sciences and then the clinical studies. One of the most important areas that I was taught was that of critical appraisal. This subject enables you to read articles and papers published in journals and elsewhere to examine whether what was said is likely to be true. Without critical appraisal, statistics and statistical analysis is just a dull bore. Now, I'm not a statistician by any standard, but it does help you sort out the wheat from the chaff. Of course, this begs the question as to how many of these papers get through the peer review process to publication. I suspect the answer is that peer review was often weak and flawed. Nevertheless, it provides the foundation for evidence-based medicine (EBM).
Science provides the basis for just about every development that mankind has made in it's history. From the invention of the wheel through to TV's and computers, landing men on the moon - none of these would have happened without the application of scientific methodology. Science therefore provides us with the tools we need to judge whether, for example, a therapy is effective for a particular disease. You learn to understand how randomisation helps reduce the possibility of trial results occurring by chance. You also learn to understand and appreciate the limitations of evidence gathered by trial methodologies other than randomised double-blinded, placebo-controlled clinical trials. Increasingly, medicine will not accept any new treatments until sufficient evidence has accumulated to demonstrate that the benefits of a new therapy are not only genuine but also outweigh the risks that the new therapy might invoke. It's all about the risk-benefit analysis.
In the years since I qualified, the growth of computer technology and the Internet has made it much easier. In  particular, the development of websites dedicated to EBM, such as the Centre for Health Evidence and the Centre for Evidence Based Medicine give access to a multitude of tools to help with the critical appraisal of papers published in the medical journals.
So, I guess I've always been somewhat sceptical (with a "c") when it comes to accepting whether a paper was to be believed or not throughout my medical career. Even when papers are extensively peer-reviewed and critiqued, it can be difficult to be confident that one study can give the answer to the problem studied. For example, the world of critical care medicine got very excited about the publication in 2001 of a study of the practice of tight glycaemic control and its apparent impact on morbidity and mortality in critical illness. Despite this being a single-centre study and the majority of patients undergoing cardiac surgery, intensive care units across the world adopted the practice, including the one where I work. There's no doubt that the stress of critical illness will result in hyperglycaemia. However, treating the patient to achieve normoglycaemia is a risky business. In the scientific literature and at conferences, many intensivists raised concerns about the applicability of the practice, the risk of hypoglycaemia and the purported benefits. Subsequent studies failed to show the benefit from the original paper. The risk-benefit analysis swung very firmly back to risk. Those units that had rushed to adopt tight glycaemic control backed away from the practice. The lesson here is not to rush into changing clinical practice on the basis of flawed studies.
This sort of problem led to an even greater reluctance to believe the results of studies published in the journals. I'll admit that I rarely have time to read articles in the depth required to reveal flaws for myself, except when I am acting as a peer-reviewer (a few times a year). Fortunately, there are plenty of resources where I can find proper critical appraisals of articles which may change clinical practices.
So, why become a skeptic (with a "k")? In the past, I'd only been vaguely aware of some forms of so-called "complementary" and "alternative" medicines (CAM). Mostly, I thought they were a load of nonsense but in themselves not harmful as long as patients used them in addition to "conventional" medicine and surgery. Stories on patients suffering harm, or even dying, from reliance purely on some form of CAM seemed extremely rare and the result of such patients (or, disturbingly, their parents or partners) being mentally deranged. I even thought, naively, that the reporting of such stories would highlight the fallacy of trusting CAM.
The first stage in my journey occurred in 2010 when my son, Rhys, was diagnosed with Crohn's disease at the age of 15. My wife and I watched our son go from an active, intelligent, hardworking school student to someone who could barely struggle to get out of bed as his illness took a grip. Finally, after the penny dropped and tests confirmed the diagnosis, he was able to start effective therapy, although it still took some months for him to get well. He'd discovered the Internet some time previously and was spending his spare time getting into Facebook, Twitter, YouTube etc. and - most importantly as it turned out - blogs. As part of his GCSE English course work he had written an essay on CAM, so he sought advice from me about assessing evidence and did a lot of research on the Internet on the various forms of CAM. Let's just say he was largely unimpressed by the evidence of efficacy! When the diagnosis of Crohn's disease was made, he began searching for information on the disease, therapeutic options and the evidence of efficacy for various conventional and CAM treatments. Being intelligent and drawing on the knowledge gained in his essay-writing, he was easily able to work out (with little help from me) what was effective and what was not. He joined a web-based support group for people with Crohn's disease.
This led to the next step in becoming a skeptic. During my son's research into Crohn's therapies, he stumble upon a substance being marketed as "Miracle Mineral Solution" or "Miracle Mineral Supplement" - MMS for short. Importantly, he found that the FDA in the USA had essentially banned it as being dangerous, issuing this warning. Scary stuff! You would think that anyone reading the warning would avoid it like the plague. Err, no. The support group he joined had a lot of interesting discussions. However, there was also a lot of discussions on CAM. That was OK, though - he would just avoid all the crap and focus on trying to distill out the useful. That was until he found mentions of MMS in discussion threads. His response was to post a link to the FDA warning. This received support from some forum members but others were of the opposite view, even going so far as to attack him in the discussion. He found that a senior member of the forum seemed to be actively promoting MMS and to be offering medical advice regarding its use. When Rhys commented on this he was temporarily banned from the forum. He did not take this lying down! He tweeted about his experiences. He and others saved copies of the pages containing the offending and offensive forum posts, so that later editing would not erase what was said. He made a video of himself describing his experiences and finally started to write about them in a blog. The rest is history!
Rather than repeat what Rhys has been up to, read it in his own words on his blog. It is absolutely incredible what he has achieved in a relatively short space of time. Since then, Rhys and I have become involved with the Cardiff branch of "Skeptics in  the pub" (SITP) movement. Rhys has appeared on "Pythagoras's Trousers" on Radio Cardiff, Radio Wales, the ITV Wales news, BBC Radio 4 and BBC 1's "The One Show". He's also spoken at "ThinkCon 2011" (part of the Cambridge Science week) and at the Bristol SITP. He will be also be speaking at a Bath SITP in the near future.
Perhaps the greatest highlight, however, was being invited to attend the "TAM London 2010" meeting in October 2010. My wife and I were invited to accompany Rhys to the meeting. I was in London for a few days prior to the meeting as I was examining for the Royal College of Surgeons of England. Before my wife arrived with Rhys on the Friday evening, I was informed by the meeting organiser, Tracy King, that the organising committee had voted to award Rhys the prize of "Outstanding Contribution to Grassroots Skepticism". Needless to say, this came as a complete surprise to him on the Saturday.  Amongst others, we met James Randi himself, The Amateur Transplants and Tim Minchin.
The things I've learned from this process? Having previously thought of the CAM business as nothing more than a harmless irritation, I now realise that it's an industry populated by deluded fools and unscrupulous bastards only in it for a quick buck. If this was at no risk, then I would be happy to take the view of a fool and his money being soon parted. However, all too often, CAM is associated with significant harm, for example the Penelope Dingle case or vertebral artery damage following neck manipulation. Simply sitting back and feeling smug about not falling for this crap, it's time to get active and fight back against people who are peddling woo. I've also realised after some "interesting" debates with various cranks on social networking sites that it can be impossible to rid people of their delusions. It's far better to keep challenging them for their evidence so that anyone inquisitive about CAM can see what shite these quacks are peddling can see that they lack credible evidence to support their ridiculous claims. Sometimes it's better to ignore the constant stream of crap these people come out with - don't feed the trolls!
Hopefully, all this has made me take a more critical look at products that are being pushed to an often unsuspecting public. The ability to take action against woo-meisters through agencies such as the MHRA, Trading Standards and (most notably) the ASA has enabled anyone to challenge the claims made on websites. The ASA acquired the ability to act against false claims made on websites in March this year was a major advance in the anti-woo fight. To make it even easier to report false claims, mega kudos must go to Simon Perry for his development of Fishbarrel, a plugin for the Google Chrome web browser. I've also become hyper-critical of new publications in critical care journals.
I think the biggest challenge now is not to let skepticism be so all-consuming that it spoils your enjoyment of other aspects of life. It's still important to be able to suspend belief sometimes to enjoy television, films, the theatre, books, etc. You can take life too seriously and become so engrossed with demanding evidence for the efficacy of anything and everything that it detracts from a happy, balanced existence.
So, skepticism is important in so many ways but you mustn't let it become so all-engrossing that it stops you from enjoying life. I hope that I'm getting to that position. It can be really difficult to stop yourself from getting so deeply involved in something like skeptical activity that you find yourself pushing other aspects of your life aside to the detriment of the well-being of yourself and your family and friends. My advice? Be skeptical, particularly when it comes to issues that affect your health, wealth and happiness. Just take care to not to drown in obsession with demands for evidence of benefit when pure enjoyment in family, friends, food, books, TV, films, theatre are every bit as important. Enjoy!

Friday, July 8, 2011

More on the Homeopathic Vet

So my comment passed moderation and received the following reply:-

Dear Paul,

Yes, I have – I have two science degrees from Edinburgh University. They took me six years to achieve. The thesis for my dissertation on immunology. What biological science degrees do you have?

The Shang paper in The Lancet in 2005 was the sixth metanalysis (the highest evidence base in Evidence Based Medicine) in the last few decades. It cherry picked a fraction of the total number of papers available and came to this negative conclusion. it also said ‘‘Homeopathy and conventional medicine showed a similar positive treatment effect overall’. The previous five metanalyses concluded that the effects of homeopathy were greater than placebo.

The House of Commons S&T Committee was prejudiced against homeopathy by Dr. Evan Harris MP an arch skeptic. In their overall conclusion they state homeopathy is placebo. The five metanalyses above suggest otherwise, so their ‘conclusive’ report is wrong. The Faculty of Homeopathy has dealt adequately with this:

Here’s some physics on ultradilution studies, from London Southbank Uni, as requested:

The 1023, How Does Homeopathy Work and the Sense About Science websites are so biased, narrow minded and unscientific that I will not grace them with even a reply.

If homeopathy does not work, could you please explain that to the thousands of animal patients that were cured with its use? You can argue with me all you like, but you can’t tell them homeopathy is merely placebo.

Here’s 145 human studies, 50 animal studies 8 plant studies and 23 in vitro studies. Can i suggest you lot stop crowing that ‘there aren’t any studies in homeopathy’:

So, Paul, can we just be a bit adult about this and agree to differ. There are children dying in Africa – why don’t you spend your considerable energy doing something to help them rather than badgering the homeopathic community in this country who are doing their best to improve health in the UK.

And then we got:-


Looks like Paul’s beaten me on the ‘who can use WordPress the best’ competition. The links I was trying to put in are:

BHA rebuttal of S&T Committe report:

Ultradilution research:

Research in homeopathy:


OK, let's have a look at this. Here's my response:-


Nick - I'm a doctor. MB BCh, FRCA.

The "Here's some physics..." link doesn't work - maybe because it's a homeopathic link! The link to the 145 human studies etc doesn't work.

Why do you claim that the 1023 campaign and Sense About Science websites are biased? Do you have evidence to support these allegations or are you simply upset/irritated/annoyed that they present evidence that is counter to your views?

Can you actually show that animals have been "cured" by homeopathy and exclude the regression to the mean that typically explains the apparent success of "alternative" therapies? Don't bother with the "homeopathy cured bovine mastitis" paper, which is fundamentally flawed:-

I have a problem with the homeopathic community claiming to improve health as - based on the currently available evidence - they are making false claims of benefit. Therefore they are deceiving the public, either by being deluded (in the true meaning of the word  - holding false beliefs) as to benefits of the therapies they claim benefit for or they are not being honest with the public. This is why the Advertising Standards Authority is dealing with the claims being made on the websites of homeopathists,

If the BHA's rebuttal of the Science & Technology Committee's was based on evidence that stands up to scientific scrutiny, then I presume that they can present their evidence to the ASA? Please note that the BHA did submit evidence to the Committee, along with a number of well-known homeopathists:-

Where has the ultradilution research been published in peer-reviewed scientific journals? The London South Bank University page gives a bunch of links to various websites, nothing peer-reviewed, frequently linking back to other pages in the same list. A common theme is linking back to the discredited work of Jacques Benveniste:-

You accuse the Shang et paper of cherry-picking and then link to an Australian homeopathist's list of research papers? What's sauce for the goose....

Meta-analyses are an excellent technique for synthesising data from varying trials to try to reach a conclusion regarding the effectiveness of a therapy. The biggest issue with conducting a meta-analysis is to ensure that the results of poorly-conducted trials do not affect the conclusions drawn from the analysis of properly-conducted trials. In Shang's analysis, they had to discount many trials due to the poor scientific methodology.

So, yes, let's be adult about this discussion. If children are dying in Africa, the last thing they need is homeopathy. Clean water, good nutrition and, when needed, treatment with proven effective medicines.

Thursday, July 7, 2011

Homeopathist Vet attacks The Nightingale Collaboration

Hmm. So this homeopathic vet tries to claim that The Nightingale Collaboration should be castigated for having the audacity to attach homeopathists but leaving arms manufacturers alone? Err? What the fuck?

I should have saved a copy of my original posting to show here but I didn't even think of it at the time. However, I posted a response which said that the ASA were obliged to act against homeopathists who make claims of therapeutic benefit which are not supported by the available scientific evidence. I also commented that by and large the arms manufacturers are hardly regarded as bastions of virtue whereas homeopathists are claiming that they are helping treat patients. I finished by saying that such a comparison was ridiculous, akin to comparing apples with coal.

My posting did not pass moderation - big surprise, NOT!

I submitted another response criticising the blog writer, which he did publish:-

Eh? "They don’t seem to have access to the most up to date thinking on homeopathy and the physics of ultradiluted substances". What thinking and physics would that be then? I've posted the following comment - let's see if this passes moderation....

Nick - you are so wrong that it is incredulous to think that you have undergone scientific training. The evidence base for up to date thinking on homeopathy and the physics of ultradiluted substances? You are joking, I presume? Seriously, what is the most up to date thinking on homeopathy? The evidence has been assessed in a meta-analysis in "The Lancet" in 2005 -

The evidence has been scrutinised by the House of Commons Science and Technology Committee - their findings were conclusive:-

The physics of ultradiluted solutions is also pretty clear - water does not have a memory and at 30c dilution the chance of finding a single molecule of active ingredient is extremely remote.

If you have evidence to suggest otherwise that stands up to scientific scrutiny, please provide it.