Friday, July 29, 2011

A Burgeoning Klatch of Science Skeptics

Stop BS The ongoing Pain-Topics series, “Making Sense of Pain Research,” has encouraged professionals and patients to develop a “healthy skepticism” toward everything they read in journals, hear at conferences, or see in the news. As it turns out, skepticism regarding modern science, including the field of pain medicine, is somewhat of an international movement. Its mantra might be “Stop the B.S.” (with the irreverent logo at right); yet, there is an apparent danger of skepticism becoming close-minded cynicism falling into the trap of contempt prior to investigation that might preclude truly objective analyses of research.

The community of skeptics, worldwide, serves an important function in modern society, as they always have. It was probably skeptics who asked, “What makes you think the Earth is flat — where’s your proof?” When it comes to healthcare, skeptics at their best evaluate medical treatments and products in a scientific light, promoting the highest standards and traditions of scientific inquiry; however, at their worst, skeptics may merely be naysayers, stirring up the pot of already-established evidence to draw attention to themselves.

The Internet as Breeding Ground

As a group, modern-day skeptics appear to be well-educated, erudite, and certainly opinionated. They largely inhabit the Internet “blogosphere,” which has allowed increasing numbers of skeptics to publicly raise questions, express their views, and create a community of likeminded folks who revel in challenging even the most accepted principles of science and medicine.

In his NeuroLogicaBlog [here], Steven Novella, MD — a clinical neurologist at Yale University School of Medicine — writes “There is no question that the advent of social media, blogs, and podcasts correlated with an explosion in the skeptical community. We went from being a loose collection of small local groups, with a few national groups largely pursuing their own agenda, to a vibrant intellectual community.”

Novella observes, “Skepticism is about promoting science, critical thinking, and reliable information. The abundance of information [on the Internet], will not lead to certainty; it will lead to pervasive skepticism.”

Finally, he concedes, “I have become thoroughly convinced of the axiom that there is no claim so absurd that it cannot attract flocks of true believers. The default mode of human psychology is to think with our emotions, then deftly rationalize our decisions. As a result there do not appear to be any practical limits to human gullibility.”

Skeptics Targeting CAM

Favorite targets in the pain management arena for skepticism include anything having to do with CAM (Complementary & Alternative Medicine), including chiropractic therapies, homeopathy, naturopathy, nutraceuticals, magnetic therapy, acupuncture, energy healing (eg, Reiki, healing touch), and others. In the blog, Science-Based Medicine [here], David H. Gorski, MD, PhD, claims that information about alternative medicine is overwhelmingly naïve and uncritical, and both mainstream media and medical institutions have bought into the hype and failed to ask the hard questions.

Gorski is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery. Academically, he is an Associate Professor of Surgery at the Wayne State University School of Medicine and part of the faculty of the Graduate Program in Cancer Biology there.

He writes, “It’s been a recurring theme on this blog to discuss and dissect the infiltration of quackademic medicine into our medical schools. Whether it be called ‘complementary and alternative medicine’ (CAM) or ‘integrative medicine’ (IM), its infiltration into various academic medical centers has been one of the more alarming developments I’ve noted over the last several years. The reason is that ‘integrative’ medicine is all too often in reality nothing more than ‘integrating’ pseudoscience with science, quackery with medicine.”

Gorski lambasts not only medical schools but institutions such as NCCAM (National Center for Complementary and Alternative Medicine) [here] and the Bravewell Collaborative [here], both of which help to fund a number of integrative medicine initiatives. He laments, “It’s been a depressing slide, and periodically I wonder just how much more pseudoscience can be ‘integrated’ into medical schools and academic medical centers or how much further medical schools can go in pandering to nonsense.”

A Gathering of Skeptics

The community of skeptics has its own annual conference, called “The Amazing Meeting,” or “TAM.” The 9th such gathering, held in July 2011, attracted 1,600 persons to Las Vegas.

TAM — promoted as an annual celebration of science, skepticism, and critical thinking — is organized by the James Randi Educational Foundation (JREF [website here]). This was founded in 1996 by Randi himself, who was once an internationally known magician and escape artist, but today is best known as an investigator and debunker of paranormal and pseudoscientific claims. He has received numerous awards and recognitions, including a Fellowship from the John D. and Catherine T. MacArthur Foundation in 1986.

The most recent TAM brought together skeptics from around the world and a long list of guest speakers and panelists. Workshops included: Defending Evolution, Skeptical Activism , Advancing Skepticism Online, Investigating Monster Mysteries, Raising Skeptics, and others. And, among the sessions discrediting UFOs and paranormal phenomena were the usual attacks against “alternative therapies” in healthcare and pain management.

COMMENTARY: Rethinking Skepticism

Throughout these Pain-Topics UPDATES, and particularly in our “Making Sense of Pain Research” series [here], we have advocated for adopting a healthy skepticism toward medical information coming from any source. More particularly, we have promoted an “educated skepticism” whereby established principles of scientific inquiry and research methodology are applied to the evaluation of evidence in the pain field for decision-making purposes.

Along with that, however, we have acknowledged that it is far easier to criticize science — asking tough questions, pointing out flaws or weaknesses — than it is to do good science. Therefore, we were somewhat dismayed by the writings and posturing of the self-proclaimed community of professional skeptics.

For example, their diatribes against CAM and integrative therapies — which actually can be vital modalities for effective pain management — seem guided more by emotional arguments than a systematic study of all available evidence. Hence, when Novella writes (as noted above), “The default mode of human psychology is to think with our emotions, then deftly rationalize our decisions. As a result there do not appear to be any practical limits to human gullibility,” we wonder if he also is describing how a credulous community of skeptics approach their subjects of scorn.

And, when Gorski asserts that “integrative medicine is all too often in reality nothing more than ‘integrating’ pseudoscience with science, quackery with medicine,” we might assume he has solid evidence to justify such claims; but, if so, he is keeping it secret. And, his far-reaching denigration of NCCAM, the Bravewell Collaborative, and unnamed medical schools adds emotive impact to arguments that might have no basis in fact.

Admittedly, the comments above from Gorski and Novella are mere snippets of their voluminous writings, described out of context. Readers can themselves visit the blogs of these skeptics (linked above) to decide the merits of their arguments. For example, we find using words like “pseudoscience” and “quackery,” as they do, to be rather slanderous and empty invectives.

Elsewhere in their blogs there are tediously verbose and wearisome debates in print about whether “science-based medicine” or “evidence-based medicine” is the more correct approach. As a further example, skeptics argue that the “placebo effect” should more properly be described as a “placebo response.” While words do make a difference, and there may be nuggets of substance in some of the rhetoric, much of it seems to be an intellectual exercise for the entertainment of their fellow skeptics — and, perhaps, the gullible public.

A commenter on one of the blogposts seems to sum up the life of a skeptic: “[S]ometimes being known to your family and friends [and colleagues, we would add] as a skeptic is a bit of a bummer because they may be reluctant to bring up certain topics for discussion, knowing that you will ‘spoil the fun’ by bringing critical thinking and skeptical analysis to the discussion. Usually these are the people who equate skepticism with close-mindedness.”

The lesson in all this is that our understanding of “healthy skepticism,” as advocated in these Pain-Topics UPDATES, may have an objective of “stopping the B.S.,” but it is not necessarily bent on “spoiling anyone’s fun.” And, it is not a close-minded approach that encourages contempt prior to adequate investigation.

Skepticism in pain research should drive a search for truth that recognizes and acknowledges the boundaries of uncertainty. Unfortunately, a great deal of research in the pain field seems driven by political agendas and hidden self-interests, so educated skeptics have much work ahead. We hope our readers are up to the task.


Anonymous said...

Strange that at some of the skeptic blogs there are “Google ads” for the very same products and services that the skeptics are grumbling about. Why would they do that -- unless their ultimate motive is to grab lots of attention and make some money in the process.

Osteofiles said...

At one point it was the skeptics who said "Prove that the earth is *not* flat".

Might does not equal right.

freetofu said...

I came upon Dr. Novella's blog a few years ago while looking for analyses of recent studies using toothpick placebos for acupuncture, and I think that, when he focuses on individual studies like these, his writing is some of the most insightful around (his verdict on acupuncture is that it is no better than placebo). I do tend to have problems with these writers when they overgeneralize, and, if I may indulge in a bit more generalization of my own, I sense some turf protection in their choice of bete noire. On the other hand, I think that generally their main concern is with the distortion of science-based medical practitioner education in the interest of CAM promotion, rather than with patient education. For a patient education-centered skeptical website I find quackwatch to be invaluable.

On the other hand, I find that this blog can err overmuch on the side of open-mindedness at times. A while back you presented a list of alternative treatments, with a request for any suggested additions from readers. I was tempted to suggest trigger point therapy and Feldenkrais technique, both of which I use to self-treat, and which don't appear ever to have been mentioned here, but I did not want them to be equated with things like energy healing.

My attitude toward mainstream vs. alternative medicine is that, within the former group their are many treatments where the scientific and evidentiary support is solid, and within the latter group there are treatments that can be confidently dismissed on the same grounds, but that there also exists within both groups a grey area where the main support comes in the form of tradition and anecdotes, and so the question that decides whether it is to be considered mainstream or CAM is, whose tradition and whose anecdotes. As a patient I would like to have guidance in navigating this grey area, and I find such guidance very hard to come by.

At the same time, I think one should remember that, in the case of pain, the symptoms are mostly subjective, and the risks of ineffective treatment are low, and therefore the common approach of throwing anything one finds at the condition and seeing what sticks, with little regard to whether it's "real" or placebo, seem to be a reasonable one from the patient's point of view.

SB. Leavitt, MA, PhD said...

Thank you, “freetofu,” for the very thoughtful comments above. I will take your statement that “this [UPDATES] blog can err overmuch on the side of open-mindedness” as a compliment; far better, in my view, than for us to be the other way around.

I apologize for leaving the Feldenkrais method and trigger-point therapy off of our holistic pain care “wish list” last December [UPDATE here]. Further, I think that “Quackwatch” is an interesting blog, but it can be overwhelming and opinionated; so, as with all others, “healthy skepticism” is advised in the reading.

I concur that, since pain can be highly subjective, somewhat questionable therapies outside of mainstream medicine may be helpful for select patients whether due to real or placebo effects. However, if a relatively unknown or unproven therapy is expensive, invasive, or has potential for harm, extra consideration and precaution are necessary -- in our opinion.

freetofu said...

I would also add that I don't think you gave a fair impression of those blogs. They may sometimes make an assertion without citing evidence (as I'd say you did a few times in this post), but a very high proportion of the the content is painstakingly documented.

Anonymous said...

I don’t know what ‘freetofu’ was expecting, but I think Dr. Leavitt was very fair --- even saying nice things about the credentials of the skeptic bloggers and giving us links so we could go to their blogs and decide for ourselves if they’re worthwhile. And, I also don’t know what ‘freetofu’ considers to be “painstakingly documented” but the way I see it those blogs ain’t it by any stretch of the imagination.

vexorian said...

Anonymous: It may surprise you but people don't really have much control on what google ads show in their pages. It is decided by an algorithm at google.

This shows the sort of power that those producing those pain stuff have.

@"Quackery and pseudoscience" : The problem is that it is Quackery and pseudoscience what they talk about most of the time. And most of the time it is the sort of pseudoscience that cause great harm to the health of society as a while. They spent a good deal of time dealing with anti-vax people, for example. And after dealing with them for enough time, I don't think it is possible not to get bitter or "emotional".

CAM is harmful to health. I don't see how can "healthy skepticism" be about not focusing on 'institutions' that harm public health. NCCAM and many proponents of so-called alternative medicine are driven by their own agendas as well.

Michael Ellner said...

I find this website to be an open-minded resource that leaves the thinking and evaluation of the subjects covered to me and that's the way I like it.

I would like to see the CAM skeptics responsibly advocate for mainstreaming "alternatives" that are evidence based. For example hypnosis, biofeedback and meditation are evidence based for pain relief and it is long past time for the inclusion of these mind-body modalities into the anthology of Pain Medicine.

Crtopher said...

If something is found to work "no better than placebo" - that's code for "it doesn't matter if you take it or not, just as long as you believe you are taking it". For some, this is acceptable, especially for pain, where a component of the sensation is subjective, but it requires one to be comfortable, and skilled, in self-deception. To call this "efficacy" is to agree to alter the definition of the word to suit one's own agenda. This is largely the criticism the science-based medicine bloggers make of CAM proponents.

To suggest that these are "diatribes", and "emotional arguments", or that they are not "painstakingly" referenced is to concede that you have no grasp of the meaning of the term "evidence" or you have willfully re-interpreted their writings in order to do your own stirring of the pot of established evidence to draw attention to yourself and this blog (to paraphrase you).

rlquinn1980 said...

Saying "we have advocated for adopting a healthy skepticism toward medical information coming from any source. More particularly, we have promoted an 'educated skepticism'[. . .]" is nothing more than special pleading. Skepticism as it is (a suspension of belief until significant evidence is produced) already includes critical thinking and the scientific method. As you cannot pass these tests, declaring that you promote "healthy skepticism" as some contrast to skepticism is nothing more than a ploy to bypass the same criticism that all over sciences have already embraced.

SB. Leavitt, MA, PhD said...

I suppose, we should get defensive, perhaps argumentative, in response to the two comments immediately above. That’s no doubt what the authors would like. However, we’re not certain in all instances what they are really trying to say.

I think that regular followers of our Pain-Topics UPDATES understand that by “skepticism” we mean a questioning attitude that does not always accept research in the pain field at face value. And, we have tried to provide discussions and tools -- and links to resources -- that will help readers to better examine and interpret the evidence to reach their own conclusions, whether or not they agree with our perspectives.

We don’t use value-laden words like “quackery,” or “junk science,” or even “pseudoscience.” And, we try to keep the discussion on a respectful and professional level. Probably, we do not qualify as “true skeptics” as the community of skeptics consider themselves --- and that’s fine with us. ---SBL

Anonymous said...

I do not recognise the bloggers at SBM in your description. I turn to Dr's Novella and colleagues to remind me to keep an open mind and look to the evidence. The term, "pseudoscience" is "value-laden". What's wrong with using a word that reflects the writer's values, (in this case, the value of sound science)? I've never found SBM "tediously verbose and wearisome", just fascinating, and it leaves me wanting more.

Anonymous said...

No skeptic can disagree with you, because “healthy” skeptics see it your way? Really? That is one of the best examples of the no-true-Scotsman fallacy that I have seen in a long time … and a real shame. If this is your skepticism, I’d hate to see your credulity!

Quackery and pseudo-science are real things, but you act like no one ever actually sold snake oil, and if they did we should shut up about it so we can all just get along. That’s just not good enough for me. I’m interested in pain science, not apologetics for CAM.

SB. Leavitt, MA, PhD said...

This little UPDATE posting above --- actually intended to alert our readers to the “Skeptics” and their blogs --- has stirred up more controversy that it’s worthy of, in my opinion. It was a stretch to begin with from our usual UPDATES topics and probably should have been left in my word processor.

The community of Skeptics seems to be a very bright bunch who are not averse to taking shots -- often personal and insulting -- at anyone who appears to disagree with them or their philosophies. Drs. Gorski and Novella literally roasted me at their blogs, at great length. I punched once and they each hit back ten times…. ouch! (I did write a note of apology to Gorski saying I never intended to malign him or denigrate his philosophies; couldn’t find an e-mail address for Novella.)

There actually is much the Skeptics have to say that I agree with, and I probably mis-communicated, a lot, in the above UPDATE. For one thing, I never intended to convey that the Skeptics are close-minded or that “Healthy Skepticism” is some sort of movement opposed to or better than theirs. For another, I do not consider myself to be an apologist for CAM or Integrative Medicine, and I often point out in these UPDATES where the research is weak or inconclusive regarding these modalities --- but, they do work for some persons with pain and that could be important. Finally, when I wrote, “…it is far easier to criticize science … than it is to do good science,” that was also an admission of what we do in these UPDATES; being critical but not doing the difficult work of original clinical research ourselves, and it was not targeted solely at the Skeptics (some of whom actually are clinical researchers).

I could go on with further clarifications, but I hope readers already get the idea. I considered redacting this UPDATE entirely, but that might be intellectually dishonest at this point. So, I’ll leave it here, with apologies to any Skeptics who feel that I was belittling them -- that was not the intention. At the same time, however, I’m not going to join in their debates since there’s too much other work to be done. -- SBL

Anonymous said...

No, please don't go. Seriously. It seems to me that you care about alleviating pain, and for that I applaud you. Your efforts can only be improved by truly engaging with the issues raised at SBM. I used to champion CAM, thinking it was benign and worth a try. I've since seen how, "the evidence is weak, but it works for some", has harmed my friends and neighbors. There is literally no end to the "treatments" that lighten their wallets, distract them from the approaches that might actually improve their lives. If "the evidence is weak", the proper response is to ask, "why is the evidence so weak?" Instead they just move on to the next predatory quack or well-meaning but deluded "healer". Am I emotional about this? You bet I am! I owe a debt of gratitude to Dr. Novella for giving me a shining model of tenacity and clear thinking, compassion for the victims and unapologetic criticism of those who victimise them. So really, I mean it, you might thank yourself for making the effort to stay tuned to the debates on SMB. I think it is the best way for influential people like you to help people in the way that you clearly want to. Thanks for your time in reading my posts.

Anonymous said...

Dr. Leavitt, I am a former CAM practitioner. I spent many years becoming increasingly disturbed at the lack of critical thinking, the hype, the anti-scientific and anti-medical venom, and the ego-driven claims that all strongly characterized my profession. I saw people spend life savings on treatments as ridiculous on their face as astrology. I saw them seriously harmed by outrageously aggressive and careless treatments and ignorance of red flags for serious medical conditions. Above all, I saw the ridiculous mental gymnastics and rationalizing that CAM practitioners constantly indulge in to evade all knowledge of or responsibility for their failures. “Healing crisis” my ass!

The only “alternative” treatments that show any promise aren’t really alternative at all — they are just things that CAM has tried to appropriate from mainstream medicine and rebrand as their own. The “big guns” of CAM, the truly CAMish stuff — homeopathy and acupuncture especially — has been proven ineffective or utterly underwhelming with such mountains of evidence that the mind boggles that anyone can still say with a straight face that they are merely “unproven medicine.”

You don’t seem to realize any of this. You are being naive about CAM. You say that you’re not an apologist for CAM, but you are indistinguishable from one when you make sweepingly positive and vague assertions like “they do work for some persons with pain and that could be important.”

SB. Leavitt, MA, PhD said...

Anonymous above concludes: “You don’t seem to realize any of this. You are being naive about CAM. You say that you’re not an apologist for CAM, but you are indistinguishable from one when you make sweepingly positive and vague assertions like “they do work for some persons with pain and that could be important.’”

Well… this is exactly the sort of debate that I do not want to get involved in… complete with insults hurled my way. Is it really professional to call someone naïve if their perspectives do not concur with your own? Just wondering.

We could argue about the evidence, or lack thereof, and what is a sweeping assertion or not, all day and get nowhere. It’s a no-win situation; just endless intellectual argument -- but you know that.

I know this… last week a fella told me that WD-40 (the spray lubricant) works wonders for relieving the pain in his shoulder from osteoarthritis. Preposterous I thought... no research on that; no plausible scientific explanation. Placebo response maybe?

He doesn’t really care – insists that it does great and he’s not about to stop using it. So… there’s a CAM therapy that isn’t even in the catalog… yet. And, its effectiveness has been demonstrated in an n-of-1 trial… so, all I need to do is find one more person it has helped and I can confidently say, “WD-40 works for some persons with pain and it is important to them.”

Anonymous said...

I posted above that I applaud you for being concerned with alleviating pain, and that your efforts might be improved by engaging with people like the bloggers at SBM. Now I think I was wrong about that. I do agree that further engagement would be pointless. The WD-40 story made me feel like you are playing a practical joke. Don't be surprised if rational people continue to challenge your views. Nobody is "hurling insults", or "hitting" you ten times because you "punched" them once. All I see are smart folks trying to promote sound science. Don't take it personally.

SB. Leavitt, MA, PhD said...

“The WD-40 story made me feel like you are playing a practical joke. Don't be surprised if rational people continue to challenge your views.”

Ah, yes… the insulting innuendo… since I am irrational, “rational people” will continue to challenge my views. I’m not being thin-skinned, and I don’t take it personally, I just do not see the purpose or propriety in professional discourse that insults the other person in order to elevate one’s own status or positions.

The WD-40 caper seemed wacko to me too, but put “WD-40 for pain” into the Google browser and you may be surprised what turns up. Apparently, many people claim it helps their arthritis. Plus, there are many warnings about hazards of using it on skin and, from what I could see, no research. So, it helps some people and it’s important to them, but it seems imprudent to recommend it for pain at this time. Is it worthy of actual research? I don’t know.

Instead, in many of the articles, healthcare professionals recommend glucosamine with or without chondroitin. Now, that’s something I’ve written about in these UPDATES and the research appears to be pretty inconclusive, mostly leaning toward the negative side… plus, those products can be somewhat pricey. Based on the evidence I’ve seen, it’s questionable whether glucosamine/chondroitin should be recommended… but I keep watching for more studies since, even in the most negative research, a certain percentage of subjects were helped (but the NNTs were high and patient-selection factors confounded the evidence).

Oh… BTW…. I think comments coming from folks who enter their name, their real name, rather than “anonymous” are taken much more seriously. Just a suggestion.

Anonymous said...

Anonymous here. I'm brand-new to the world of social media and commenting on bogs, (yours was my first), and am fearful of putting my name "out there" until I know what I'm doing. I have received some threatening responses to my face-to-face criticism of CAM, and am not yet brave enough to make my identity known on the blogosphere. I am not a physician or scientist, but a small-town daycare worker. My anonymity is irrelevant to my message.

You touched on a key theme in the world of skepticism - It is objectionable to profit from promoting bogus treatments for which there is no strong evidence of efficacy, (in this case glucosamine), no matter who does it - a "quantum healer" or a family physician. Treat yourself to Ben Goldacre's book, "Bad Science - Quacks, Hacks and Big Pharma Flacks".

I was sincere in wondering if the WD-40 story was a joke that I just did not get.

SB. Leavitt, MA, PhD said...

I invite readers to visit the Skeptic blogs -- start with those linked in the UPDATE above -- and decide for themselves. Spend some time, not only reading the words but also considering the tone and the attitudes expressed. Is the posture one of intellectual inquiry, judiciously considering various sides of the topic being examined, or of authoritarian dogma? Are you exhausted and exasperated after the reading, or do you feel that you have learned something of value.

Be sure to read the comments -- these are from your fellow travelers at the website. Are these the sort of folks you want to “hang out” with? Enter a comment of your own, questioning or mildly disagreeing with something that is said. See what sort of welcome and reaction you receive. Are they respectful of your divergent opinions?

I tried not to be judgmental in the suggestions above. Readers can decide for themselves if joining the community of Skeptics is how they want to spend their precious time.

Anonymous said...

"couldn’t find an e-mail address for Novella"

Try typing in "steven novella email". It took me less than a minute to find it.

SB. Leavitt, MA, PhD said...

Thanks for the suggestion. I received a nice reply from Dr. Gorski to my note, and both he and Dr. Novella have moved on to other important topics -- which I have done also. So, it's probably time to put this particular UPDATE aside. -- SBL