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Oct 22 Saturday The High DriveToday I got on 26th street next to the Hotel and took it Southwest till it became Gold Camp Road and then climbed up and up to follow the Gold Camp road where it goes around a very scenic route and through 2 tunnels on a very narrow road. It was paved then turned to gravel and got so rough I started to say heck with it and turn around but it smoothed out a bit and bec
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Het avondje uit in de reggae pub bleek een groot succes te zijn We waren met zn vieren Ian van de UK Clement van Frankrijk een Oostenrijker wiens naam ik niet meer weet en ikzelf. Het was supergezellig maar vreselijk uitputtend om zo lang een Engelse conversatie aan de gang te houden Ik ben ervan verschoten hoe slecht het gesteld is met mijn Engelse kunde ik lijk wel terug op hetzelfde ni
Steve Jobs’ medical reality distortion field
As I pointed out in my previous post about Steve Jobs, I’m a bit of an Apple fan boy. A housemate of mine got the very first Mac way back in 1984, and ever since I bought my first computer that was mine and mine alone back in 1991 (a Mac LC), I’ve used nothing but Macintosh computers, except when compelled to use Windows machines by work—and even then under protest. Indeed, as I searched for jobs at various times in my life, I asked myself whether I could accept a job at an institution that didn’t permit me to have a Mac in my office, such as the V.A. Fortunately, I never had to make that choice. All of this explains why I paid a lot of attention to Steve Jobs and also why his death saddened me and, relevant to this blog, the clinical history of the cancer that killed him fascinates me.
It’s often been said that there was a sort of “reality distortion field” around Steve Jobs. It was a part joking, part derogatory, part admiring term applied to Jobs’ talent for persuasion in which, through a combination of personal charisma, bravado, hyperbole, marketing, and persistence, Jobs was able to persuade almost anyone, even developers and engineers, of almost anything. In particular, it referred to his ability to convince so many people that each new Apple product was the greatest thing ever, even when that product had obvious flaws. Unfortunately, as more news comes out about how Steve Jobs initially dealt with his diagnosis of a neuroendocrine tumor of the pancreas (specifically, an insulinoma) back in 2003 and 2004, it’s become apparent that Jobs had his own medical reality distortion field, at least in the beginning right after his diagnosis of a rare form of pancreatic cancer, that allowed him to come to think that he might be able to reverse his cancer with diet plus various “alternative” modalities.
In the immediate aftermath of Steve Jobs’ death, I summarized the facts about Jobs’ case that were known at the time. In particular, I took issue with the claims of a skeptic that “alternative medicine killed Steve Jobs.” At the time, I pointed out that, although it was very clear that Steve Jobs did himself no favors by delaying his initial surgery for nine months after his initial diagnosis, we do not have sufficient information to know what his clinical situation was and therefore how much, if at all, he decreased his odds of survival by not undergoing surgery expeditiously. To recap: Did Steve Jobs harm himself by trying diet and alternative medicine first? Quite possibly. Did alternative medicine kill him? As I’ve argued before, that’s impossible to say, and any skeptic who dogmatically makes such an argument has taken what we known beyond what can be supported. Regular readers know that when I see a story that looks as though “alternative medicine” directly contributed to the death of someone, I usually pull no punches, but in this case I had a hard time being so definitive because the unknowns are too many, with all due respect to Ramzi Amri, a Research Associate at Harvard Medical School who in my opinion also went too far. I did, however, point out that I’m always open to changing my opinion if new evidence comes in. Jobs was always incredibly secretive about his medical condition, so much so that it didn’t even come out in the press until after it had happened that he had undergone a liver transplant in 2008 for metastatic insulinoma in his liver, just as his cancer diagnosis in 2003 remained secret for 9 months, not being revealed until he sent an e-mail to Apple employees announcing that he had undergone surgery.
It turns out that, with the imminent release of a major biography of Steve Jobs, more information is finally trickling out about his medical history. For instance, Jobs’ biographer Walter Isaacson is going to appear on 60 Minutes this Sunday, and apparently he is going to say this:
Everyone else wanted Steve Jobs to move quickly against his tumor. His friends wanted him to get an operation. His wife wanted him to get an operation. But the Apple CEO, so used to swimming against the tide of popular opinion, insisted on trying alternative therapies for nine crucial months. Before he died, Jobs resolved to let the world know he deeply regretted the critical decision, biographer Walter Isaacson has told 60 Minutes.
“We talked about this a lot,” Isaacson told 60 Minutes of Jobs’s decision to treat a neuroendocrine tumor in his pancreas with an alternative diet rather than medically recommended surgery. “He wanted to talk about it, how he regretted it….I think he felt he should have been operated on sooner… He said, ‘I didn’t want my body to be opened…I didn’t want to be violated in that way.’”
Isaacson is also quoted as saying about Jobs:
He’s regretful about it… Soon everybody is telling him, ‘Don’t try and treat it with these roots and vegetables and these kinds of things…’ By the time they operate on him they notice it has spread to the tissues around the pancreas.
You know, I think I’ll have to buy this book when it comes out next week, if only to read the chapters on Jobs’ illness. Assuming that the account above is true, what does it tell us? First, it doesn’t significantly change my original assessment that, at the time of surgery in 2004, Jobs probably didn’t have metastatic disease. The reason I say that is because if Jobs had any evidence of metastatic disease, it is highly doubtful that a surgical oncologist would have undertaken as huge an operation as the Whipple procedure, an operation that is usually only performed with curative intent. It’s very rare that this operation is done for solely palliative purposes, because the potential for complications is fairly high, and even when there are no complications it permanently alters the GI physiology of the person undergoing it. With that in mind, the report above implies to me is that Jobs’ tumor had grown larger and started to invade through the capsule of the pancreas into the surrounding fatty connective tissue. Further, it’s also not clear whether this tumor was seen on imaging before his operation or whether it was the finding of microscopic tumor deposits outside of the pancreas in the surgical specimen removed. Given how indolent insulinomas usually are, especially if they’re functional, as Jobs’ tumor appears to have been from all news reports (when it recurred Jobs attributed his medical leave to a “hormone imbalance”), it’s not clear that his surgeon wouldn’t have found tumor spread found outside of the pancreas if he had undergone surgery right away. As Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society has pointed out, people “live with these tumors far longer than nine months before they’re even diagnosed.” I suggest going back and read my post on the early detection of cancer, particularly the part about lead time bias, for an explanation of why the nine month delay might not have mattered much. As I have said before, biology is king and queen, and for certain tumors in certain patients biology trumps whatever we can throw at them.
Another interesting tidbit of information coming out just now is just what Jobs did during those nine months during which he delayed having surgery. This ABC News report hints at it:
Jobs, fascinated by Eastern mysticism in his youth, believed in alternative herbal treatments, and sources have told ABC News in the past that they thought he minimized the seriousness of his condition. One source close to Jobs said he kept his medical problems private, even from members of Apple’s board of directors — who finally had to persuade him his health was of critical importance to Apple’s success and the value of its stock to shareholders.
And this AP report states:
Instead, he tried a vegan diet, acupuncture, herbal remedies and other treatments he found online, and even consulted a psychic. He also was influenced by a doctor who ran a clinic that advised juice fasts, bowel cleansings and other unproven approaches, the book says, before finally having surgery in July 2004.
This is fairly vague, although one wonders if this acupuncturist is identified in the book, you know, the one who allegedly told Dr. Nicholas Gonzalez that she was trying to get Jobs to see him. Maybe Gonzalez wasn’t lying after all, because the description in the passage above does sound a lot like the Gonzalez protocol, which involves juice fasts, a whole lot of supplements, various other radical diet manipulations, plus daily (or more) coffee enemas. Could it be that Gonzalez did for a while influence Jobs?
Perhaps the book will tell.
Then there’s this video from the ABC News report:
There he is, at right about the 2:00 mark: Dr. Dean Ornish. In fact, from the news report, it appears that Dr. Ornish was not only Jobs’ friend but his doctor as well. Dr. Ornish is a problematic woo-prone physician in that, while hanging out with the likes of Andrew Weil, Rustum Roy, and Deepak Chopra, he tries to do actual science but unfortunately just doesn’t do a particularly good job of it. That in and of itself wouldn’t be so horrible, except that he draws very strong inferences from what his data show that go far beyond what is supportable by the science. Despite all these problems, there is still hope that Ornish is reachable by science-based medicine; he just has to give up his tendency to keep linking his diet with “complementary and alternative medicine” (CAM) and “integrative medicine” and embrace more rigorous, hypothesis-grounded science.
So, until I can get my hands on the book (and actually have time to read it, or at least the chapters on Jobs’ illness), what can I reasonably conclude based on what is known now? First, my original assessment has changed only slightly. Based on this new information, it appears likely to me that Jobs probably did decrease his chances of survival through his nine month sojourn into woo. On the other hand, it still remains very unclear by just how much he decreased his chances of survival. My best guesstimate is that, thanks to the indolent nature of functional insulinomas and lead time bias, it was probably only by a relatively small percentage. I also feel compelled to point out that accepting that Jobs’ choice to try “alternative medicine” first probably decreased somewhat his chances of surviving his cancer is a very different thing than concluding that “alternative medicine killed Steve Jobs,” which is in essence what Ramzi Amri and Brian Dunning both did. The first statement is a nuanced assessment of probabilities based on science and taking into account uncertainty; the latter statement is black-and-white thinking, in essence the mirror image of Nicholas Gonzalez’s claim that if only Jobs had come to see him he could have been saved.
Finally, what does this incident say about alternative medicine for cancer? Certainly, it shows that even someone as brilliant as Steve Jobs can be prone to denial, and, yes, even magical thinking, as this ABC News report points out:
How could Jobs have made such a decision?
“I think that he kind of felt that if you ignore something, if you don’t want something to exist, you can have magical thinking…we talked about this a lot,” Isaacson told CBS News.
No doubt that’s another key component of the appeal of alternative medicine: Magical thinking. Just eat this root, do these colon cleanses, let this healer manipulate your energy fields, and everything will be fine. No nasty invasive surgery that will permanently alter your body and how it functions. No poisonous chemotherapy. Unfortunately, reality doesn’t work this way, no matter how powerful the reality distortion field. Ultimately, reality intrudes, as it did for Jobs. When it did, when a followup scan apparently revealed that his insulinoma had grown, Jobs realized he had made a horrible mistake and tried to correct his course by undergoing surgery right away. It’s not clear whether his time in his self-created medical reality distortion field ultimately led to his demise or whether his fate was sealed when he was first diagnosed. Again, there’s just too much uncertainty ever to know for sure, and even if Jobs did decrease his odds of survival significantly it’s impossible to say whether the delay meant the difference between life and death in his specific case. What is clear is that no reality distortion field can long hold cancer at bay. Reality always eventually wins over magical thinking, no matter how much it might appear that magical thinking is winning at any given time.
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Alternative Vaccination Schedules
Evidently the 7 billionth human is going to be born on October 31. Happy birthday and welcome to the Earth. If you were unfortunate enough to be born into a developing country or a affluent California family, you may not receive your vaccinations, and may join one the 57 million who die each year of vaccine preventable diseases (VPD).
And if you are doubly unlucky, you may be exposed to illness from an unvaccinated friend, family or health care worker before you can get your vaccines, and join the ranks of the ‘only’s.’ The ‘only’s’ are those who die of vaccine preventable diseases and are mentioned in anti-vaccine literature in a sentence like ‘VPD X is a mild illness in most children and only kills Y% of cases ’. As I have said before the anti-vaxers do not care for whom the bell tolls.
I am no good at statistics. I signed up for, and dropped, statistics at least 4 times in college. Once they got past the bell shaped curve, it was one incomprehensible huh? Part of the problem with statistical concepts such as risks, both relative and absolute, is that it is often impossible to get a feel from what they represent. For me it is like metric measurements. I know what a 8 mile hike represents, but not an 8 kilometer hike. Same with centigrade and liters. I have been unable to internalize what metric means in my daily life.
Some statistics I have to accept with no real feeling as to their magnitude. That estimated 57 million deaths from vaccine preventable illness? That’s a number I can’t wrap my head around. It translates to about 148,000 a day, or the population of my home town Portland, dying every two days. I can’t imagine that volume of death. In 30 years I have seen exactly one death from a VPD, a pregnant female who developed chickenpox and its resultant pneumonia. Chicken pox, hepatitis A and B, and pertussis are the only viral VPD’s of which I have seen more than one case. The only vaccine preventable illness I see routinely, and I should put preventable in quotes because I am not so sure the disease is currently preventable in adults, is the Pneumococcus. Certainly vaccination of kids with the conjugate vaccine has lead to a decrease in disease in adults, but that appears to be a temporary victory and the vaccine for adults, the Pneumovax, is of marginal efficacy.
I know intellectually that VPD’s are a major source of morbidity and mortality in the rest of the world, and that they, along with many other infections, are an airplane flight away from starting an outbreak. It has happened with mumps and measles, and it will happen again. But VPD’s have virtually no impact on my day to day experience as an infectious disease doctor and as head of our Infection Control programs. My time and energy are directed elsewhere.
What are parents to do? When raising kids in the US there is no need to worry directly about VPD’s. It is more a theoretical worry, because thanks in part to vaccines, the childhood plagues of the past are history, and who needs to fret about history when there are real risks to your children. I wonder, given the hassle of getting the kids to the pediatricians, how compulsive I would have been about getting my kids vaccinated on schedule if it were not a requirement for school. I probably would have kept reasonably on track, like my dental cleaning, but would not have been the model of promptness, given the lack of VPD’s in the community. It is nice to have the stick of the educational system keeping us honest, and the schools are wise to have immunization as a condition of enrollment. Schools represent an excellent center for rapid infectious disease amplification and spread.
Laziness is evidently not the main reason that parents do not get their kids vaccinated according to the CDC guidelines. Pediatrics this month has an article, Alternative Vaccination Schedule Preferences Among Parents of Young Children, that evaluated why parents are using alternative vaccine schedules. They polled the parents of kids between the ages of 6 months and six years of age about their utilization of the vaccine schedule, and I can’t decide if the results are good or bad, given the large number of irascible contrarians in the US population. Or perhaps I watch too much cable news. I am an optimist at heart so I suppose the glass is half full, albeit with bile.
13% of parents interviewed were using an alternative vaccination schedule, but only 2% refused all vaccinations. Most, rather than no vaccination, refused some vaccinations or waited until the children were older before giving the vaccination. So is 2% complete refusers, a low number or a high number? Does 13% qualify for an only? Is 87% great? Well, no. For most diseases, the coverage rates you want to maximize herd immunity for those who cannot be immunized is in the 95% plus range. I always emphasize for the housestaff that the first word in my medical subspeciality is infectious. Not kind of infectious or sort of infectious. These beasts have evolved to rapidly jump from person to person and it takes very little exposure for them to cut loose in populations. In the old days my field was called contagious diseases, and I kind of prefer that title, even though most of the diseases in the hospital are no longer particularly contagious.
Good news: “Among the alternatively vaccinating parents, only 8% reported using a well-known alternative schedule, such as those promoted by Dr William Sears (6%) and Dr Donald Miller (2%).” It would appear that the advice of Dr. Sears et. al. is being mostly ignored by the alternative vaccinators.
Bad news: However, with true American do-it-yourself Dunning Kruger gumption,
it was more common for alternative vaccinators to indicate that they themselves (41%) or a friend (15%) had developed the schedule. Among the 36% of respondents who endorsed the “other” response to this query, several indicated in the free-text section that they had “worked with their child’s physician” to develop the alternative schedule.
A do-it-yourself vaccination schedule. It flabbers my gaster. Having spent most of my adult life thinking about infections and their treatment and prevention, I find the field almost impossibly difficult. The decisions that go into the CDC vaccination schedule represent the best opinion of some the brightest and most experienced minds in medicine who are not me. Joke. Really. I would only question the CDC if I had spent three professional lifetimes in the field of vaccinations. And yet time with the googles and talking with friends and family is evidently enough to come up with your own approach to the vaccination schedule. I am glad these parents are not also responsible for deciding on doing an appendectomy or piloting my airplane. I have asked this in the past, but what is it about medicine where people think they can know better with no experience and little education? It is my field of expertise and I am more often in not uncertain if I know better.
It would appear that physicians may be a bigger problem. Co-dependent is the term, I think.
While 8% had to change providers because they wanted to use an alternative schedule and
30% their child’s doctor “seemed hesitant to go along” with their vaccination preferences but still agreed to do so, 40% indicated that their child’s doctor “seemed supportive” of their vaccination preferences, and 22% indicated that their child’s doctor had been the one to suggest using an alternative vaccination schedule.
Of 2064 respondents, 59 (22% of 13%) found a physician who recommended an alternative schedule. We do not know if that was a bias (parents knew about that providers dirty little secret when choosing a doctor for their child) or the number of docs promoting potentially dangerous vaccination schedules is much higher than I would have thought. Still, that is almost 3% of doctors who are, well, wackaloons. 3% is not an only. 3% is appalling. Would you want 3% of your surgeons to have a severe shake or 3% of your pilots to have narcolepsy?
It is interesting to see what vaccines the parents elected not to give to their kids or delay in giving.
It reminds me of the Eisenberg article in the NEJM http://www.ncbi.nlm.nih.gov/pubmed/8418405 where it was purported that 35% of Americans use alternative medicine. When you look at the data, it is only by using an extremely broad definition of unconventional including relaxation techniques and commercial weight loss programs could the 1 in three statistic be reached. Real wackaloon therapies like homeopathy and energy healing were in the 1% range. I found that table of unconventional medicine use in that continually favorably spun article reassuring, not worrisome. Americans are not as gullible as the SCAM proponents would wish. I try and keep that in mind when I watch Presidential debates. Repeat after me. Americans are not THAT gullible.
Even though AOA, Jenny McCarthy and others have worked hard to spread fear about vaccinations and have gladly taken credit for that fear, it appears that the message is not as effective as they might wish.
The list is, very arguably, reassuring. As far as the disease severity is concerned, the list is roughly in order of morbidity and mortality risks for kids. If I had to rank vaccines in the order I would give them up if forced, that is about the order I would do it. I would give up flu vaccination first and polio and pertussis last, although it is akin to deciding in what order I would like organs removed. I really would just as soon keep them all, thank you very much.
However, a glass 6 to 86% empty, it is still not full. Herd immunity and the group benefits are, I know, a poor reason to recommend vaccination. Presidential politics reminds me that there is always a strong ’screw you’ sentiment in the US. I only saw it on the Daily Show, but I think Ron Paul being asked if he would let an uninsured patient trauma just die the archetype of that attitude. Being your brothers keeper is low on the US to do list, and if my child’s lack of vaccination leads to someone else illness and death, so be it. There was a time when the concept of a rising tide lifting all boats was a public health concept embraced by most, when we worked together for the common good. A life in medicine has definitely demonstrated that that idea, if indeed it was once alive, is dead and buried with a stake in the heart, beheaded and covered in garlic, not that health care and public health is a vampire.
The attitude of ‘me first’ is oddly seen in health care workers, as I subscribe to the idea that in medicine you have an obligation to always put your patients first. Despite hospitalized patients being particularly susceptible to acquiring influenza, that about 1 in 5 cases of flu are subclinical and if acquired in the hospital, the patient has a 27% chance of dying of flu, 36% or more of HCW’s refuse the flu vaccine each year. It is not as if they have some special knowledge that prevents them from receiving the flu. They give the same old dumb ass reasons every year.
Still, even small decreases in vaccination rates have disproportionate adverse consequences, as “1% increase in the proportion of school-aged children who were underimmunized, the risk of pertussis infection among fully vaccinated children doubled.” I would wager that there are similar ill effects from avoiding other vaccines; it would seem plausible. But how does a parent understand the abstract concept and act accordingly when there is no disease in their immediate environment? Only Sherlock Holmes was wise enough to understand the significance of the dog that did not bark. I had a similar problem with hand hygiene for years, the lack to understanding that not washing hands today leads to an infection tomorrow. It took a decade of intensive work as well as a change in how hands are hygienated (from soap and water to alcohol foam) to take rates from 20% to 95%, although I suspect the real driving force was the knowledge that infection rates were going to be published for all to see. Impending public embarrassment is a powerful motivator.
The main reason (61%) of parents altered the vaccination schedule is ‘it seemed safer’. It is better to feel safe than to be safe; the spirit of Fernando lives on. These parents were also more likely to see the risk of disease and transmission to be less, and have more non-mainstream vaccination beliefs; it seems that the ‘too many, too soon mantra’, of the anti-vax proponents is resonating with alternative vaccinators. If there is a fear of autism as a reason for changing the schedule, it is not addressed in the paper. However by delaying the vaccinations past the age of onset of autism diagnosis, parents may feel safer in giving their children the vaccines. It would have also have been interesting to know what particular fears and experiences lead to the use of an alternative vaccination schedules.
Rare adverse experiences, even if not casual, can have a disproportionate influence on future behavior. I know clinically I remember bad outcomes with far more clarity than the successes. Even when I know the complication were unrelated to my therapeutic intervention or a known, and rare, complication of care (like deafness from aminoglycosides from treatment of enterococcal endocarditis), where I can at least rationalize that it was the occasional misfortune that happens as part of even the best of care, on occasion I still have to fight the urge not to repeat the past intervention for fear of a repeat of the same complication. It is hard not to give in to the fear, even when I know the fear is irrational.
It could be a lot worse. The glass could have been even emptier.
…nearly 1 of 4 parents (22%) following the recommended schedule disagreed or strongly disagreed that the schedule “recommended by vaccination experts” was the best one to follow. Similarly, 1 of 5 parents who followed the recommended vaccination schedule thought that delaying vaccine doses was safer than providing them according to the recommended schedule.
I find that a curiosity, that a significant number of patients were choosing to do something to their kids that they did not think was best for them. There is no reason given for that choice, but there appears to be a sizable number of patients are at risk to opt out of the vaccination schedule if given the opportunity. Equally curious is the 19% of alternative vaccinators who think delaying vaccination increases the risk of infection and spread of diseases, yet delay all the same. Do they think that the risk of the vaccine is greater than the diseases? They must, although the sign of an educated person is the ability to hold two contradictory thoughts in the head at the same time.
The preponderance of information in the medical literature on vaccinations is as clear as any topic in medicine. Vaccines are effective and they are safe. The best bet for keeping your child, and your community, healthy is to get vaccinated and to do it on schedule. There are people who see the issue differently, and is often the case, the reasons are more subtle and complicated that one would except. And there is still much to be understood as to why people do and do not participate in the vaccination schedule.
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The Cure
Legislative Alchemy
In Legislative Alchemy I: Naturopathy, II: Chiropractic and III: Acupuncture, we learned how state legislatures transform scientifically implausible and unproven diagnostic methods and treatments into legal health care practices. Examples typical of the sheer nonsense found in both proposed and actual legislation include:
Naturopathic health care [is] a system of health care practices for the prevention, diagnosis, evaluation and treatment of illnesses, injuries and conditions of the human body through the use of education, nutrition, natural medicines and therapies and other modalities which are designed to support, stimulate or supplement the human body’s own natural self-healing processes.
[Chiropractic is] the science of adjustment, manipulation and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that may interfere with the normal generation, transmission and expression of nerve impulse between the brain, organs and tissue cells of the body, which may be a cause of the disease, are adjusted, manipulated or treated.
[Acupuncture is] a form of health care that is based on a theory of energetic physiology that describes and explains the interrelationship of bodily organs or functions with an associated acupuncture point or combination of points that are stimulated in order to restore the normal function of the bodily organ or function.
This is gobbledygook, tarted up with a few scientific-sounding terms — “physiology,” “tissue cells,” “diagnosis.”
We know in fact that:
- Naturopathy’s basic premise is simply a restatement of long-discredited vitalism.
- The chiropractic “vertebral subluxation” does not exist, so it can’t “interfere” with anything,
nor can it be “adjusted.” - There is no “energetic physiology,” theoretical or otherwise.
The legalization of nonsense as health care has a deleterious effect on the public. Each year, millions in the U.S. visit state-licensed naturopaths, chiropractors and acupuncturists, exposing themselves to diagnoses of conditions that do not exist and treatments for these non-existent conditions, as well as treatment of real diseases with implausible and ineffective therapies. They will spend millions of dollars on these visits, paying with either their money or yours.
Although it is reasonable to assume that correct diagnosis of a real disease or condition will be at times foregone and effective treatment delayed in these visits, we don’t really know the full extent because no one appears to be looking at this issue in a systematic way, although we do have anecdotal reports. As well, it is reasonable to assume that these unnecessary treatments for imagined conditions will be injurious in and of themselves in some cases. Again, all we have are anecdotal reports, as no one is collecting the data in any systematic way.
Which brings us to . . .
The Cure
One possible solution is that states stop further licensing of “CAM” providers. Although I have not researched the issue, I do know of one instance in which this occurred. In 1959, the Florida legislature abolished the licensing authority for naturopaths, although anyone who had a license at that time was allowed to continue practicing. Anyone else holding himself out as a naturopath in Florida can be prosecuted for the unlicensed practice of a health care profession. Attempts to re-established naturopathy licensing in Florida have failed.
As you can well imagine, it would be a long, contentious, expensive and laborious process to halt the licensing of chiropractors in all 50 states, acupuncturists in 43 states and naturopaths in the 16 states where they are currently licensed.
A second, simpler solution presents itself in the form of curtailing the use of implausible and unproven practices via legislation without directly repealing the “CAM” provider practice acts. The basic premise is that scientifically plausible health care practices can be used unless and until they are shown not to work. Implausible practices, however, must meet a higher standard. In other words, it is in essence “extraordinary claims require extraordinary evidence” fashioned into health care consumer protection law.
Before looking at how this might be achieved, let’s begin with proposed legislative findings. These are typically recited at the beginning of a bill and become part of the bill’s legislative history. In turn, should a court need to interpret particular language in the bill once it is enacted into law, the legislative history can be used in determining what the legislature meant, referred to as “legislative intent.”
We will call our proposed state legislation
The Science-Based Healthcare Practices Act
Legislative Findings:
Whereas, the Legislature finds that those healthcare practices not based on generally accepted scientific principles and those healthcare practices which have been proven ineffective:
cause unnecessary expenditure of time and money by the public for ineffective treatments; and
expose the public to the risk of delay of appropriate and timely diagnosis and treatment; and
violate nationally and internationally accepted ethical norms; and
pose an unnecessary risk to the public health by exposing the public to treatments that carry risk of harm without a sufficient benefit to justify that risk.
Whereas, the Legislature finds that healthcare practices not based on generally accepted scientific principles misrepresent the sciences of biology, physiology, anatomy, physics and chemistry to the public, which undermines the legitimate public interest in a scientifically literate citizenry.
Therefore, the Legislature finds that it is in the best interest of the public health, safety and welfare to protect the public from healthcare practices which are not based on generally accepted scientific principles or have proven ineffective.
“Extraordinary claims require extraordinary evidence”
The proposed statute would read, in part, as follows:
Sec. XXX.xxx, (Your State’s Name Here) Statutes
(1) Notwithstanding any other provision of (Your State) law, no healthcare practitioner licensed by this state shall engage in the diagnosis, treatment, operation, or prescription for any human disease, pain, injury, deformity, or other physical or mental condition if such diagnosis, treatment, operation, or prescription is implausible because its implied mechanisms or putative effects contradict well-established laws, principles, or empirical findings in chemistry, biology, anatomy or physiology, and it is either
(i) not supported, to a reasonable degree of scientific certainty, by good quality randomized, placebo-controlled trials, or
(ii) not supported, to a reasonable degree of scientific certainty, by a Cochrane Collaboration Systematic Review or a systematic review or meta-analysis of like quality.
The standard “is implausible because its implied mechanisms or putative effects contradict well-established laws, principles, or empirical findings in chemistry, biology, anatomy or physiology” was taken from “Illinois Department of Professional Regulation Medical Disciplinary Board (MDB). Board Policy Statement: Complementary and Alternative Therapies. November 1999,” quoted in an SBM post by Dr. Kimball Atwood. While the Illinois Department of Professional Regulation’s policy was, as a whole, disappointing, its definition of “implausible” is useful.
The level of evidence required in for implausible practices is based on R. Barker Bausell, Snake Oil Science: The Truth About Complementary and Alternative Medicine (New York: Oxford University Press 2007), Chapter 11 (“What High-Quality Trails Reveal About CAM”) and Chapter 12 (“What High Quality Systematic Reviews Reveal About CAM”).
Why, you may ask, if a practice is implausible, would we allow it at all? Why the provision regarding studies?
This is a perfectly reasonable criticism and if you wish to go ahead with the process of eliminating such practices altogether from state law, please do. I simply offer this as a solution which might be politically achievable, as the proposed legislation does not actually do away with any “CAM” provider type.
In opposition to this legislation, “CAM” providers would be put in the position of arguing that their diagnostic methods and practices are not implausible, which is fairly easily defeated per the legislation’s definition. Alternatively, they would have to argue that, even if implausible, their diagnostic methods and therapies should be permitted anyway. This is, of course, what is already happening — they are used despite implausibility and lack of evidence,a position “CAM” providers currently need not defend once they achieve licensed health care provider status.
I also agree that it is not a good idea to spend considerable resources testing biologically implausible claims and this post is not an argument that even more resources should be expended doing so. But, while the U.S. government is at it, we might as well put the results to some good use.
The proposed legislation’s “out” based on high-quality trials also helps avoid a claim of direct conflict between the “CAM” practice acts and the new law, a conflict that would invariably wind up in the courts. For example, the proposed law does not prevent a chiropractor from claiming he can detect “subluxations” in a patient and proceeding to “adjust” them for the purpose of, say, treating the patient’s asthma. But because detection and adjustment of subluxations in general and its effectiveness in treating asthma in particular are highly implausible, a chiropractor will need an high level of evidence to legally make this claim. That evidence does not currently exist — and let me just go out on a limb here and predict it never will.
Likewise, an acupuncturist is not prevented from recommending acupuncture to treat infertility but, again, because of the implausibility of the proposed underlying mechanism of acupuncture and its putative effect on infertility, he must meet a high level of evidence to make that recommendation and commence treatment. Again, the evidence isn’t there and, again, I’ll predict it won’t be in the future.
Ordinary claims require ordinary evidence
But, what about those diagnostic methods and therapies, like chelation, which, at least initially, seemed plausible, but, even though disproved, continue in use?
For them, we have this:
(2) Notwithstanding any other provision of (Your State) law, no health care practitioner licensed by this state, shall engage in the diagnosis, treatment, operation, or prescription for any human disease, pain, injury, deformity, or other physical or mental condition even if such diagnosis, treatment, operation, or prescription is plausible because its implied mechanisms or putative effects are in accordance with well-established laws, principles, or empirical findings in chemistry, biology, anatomy or physiology, if
(i) good quality randomized, placebo-controlled trials, or
(ii) a Cochrane Collaboration Systematic Review or a systematic review or meta-analysis of like quality,
demonstrate, within a reasonable degree of scientific certainty, that said diagnosis, treatment, operation or prescription is not effective for said human disease, pain, injury, deformity, or other physical or mental condition.
The Science-Based Healthcare Practices Act would not eliminate all implausible and unproven healthcare. For example, a diagnostic method like thermography for breast cancer detection might slip by the implausibility test and remain on the market, not because it’s a reliable diagnostic tool, but because no trial meeting our statutory standard says it isn’t reliable.
And just to be sure
I propose a few other provisions to avoid attempted end-runs around the legislation’s purpose.
To help forestall any fudging on the science, the following would be included:
“Each term in this section shall be interpreted according to its generally accepted meaning
in the scientific community.”
To make clear that “subluxations,” “qi,” vitalism and the like do not get a pass on science simply by virtue of their inclusion in the practice acts:
“It shall not be a defense to prosecution for a violation of this section that a diagnosis, treatment, operation, or prescription is within the scope of practice, as defined in Chapter X, (Your State) Statutes, of a healthcare practitioner accused of said violation.”
And, to help ensure that poor quality trials cannot be used to buoy scientifically implausible health care practices (with thanks again to R. Barker Bausell, Ph.D.),
“Good quality, randomized placebo controlled trial,” shall mean a trial meeting the following minimum criteria:
(i) involving the random assignment of participants to a credible placebo control group; and
(ii) employing at least fifty participants per group; and
(iii) losing no more than 25 per cent of its participants over the course of the study; and
(iv) published in a high-impact, peer-reviewed research journal.”
Enforcement
Now that we’ve created a prohibition against implausible practices without really good evidence that they actually work, as well as plausible ones that don’t work, how to enforce it?
That authority could be given to the various boards which currently oversee health care practitioners but this seems inconsistent with the purpose of the act. If the legislature is trying to erect a barrier of scientific evidence (both basic and clinical) between the practitioner who employs implausible diagnostic methods and therapies and the patient, then the very practitioners who ignore science would not seem best suited to the task.
The medicine and osteopathic boards might be suitable to enforce our proposed legislation as against M.D.s and D.O.s, but even medical boards have proven reluctant to discipline physicians whose practice includes implausible and unproven therapies. In fairness, perhaps they were hamstrung by lack of statutory firepower sufficient to specifically address implausible, unproven and disproven practices.
One solution is to give enforcement authority to the state agency overseeing the unlicensed practice of a health care profession. This agency would already have the investigational and prosecutorial bureaucracy in place to proceed. Here, our proposed statute adopts its enforcement procedures from Florida’s “Unlicensed practice of a health care profession” statute, which gives the Department of Health (DOH) the authority to investigate and prosecute.
Briefly, if the DOH has probable cause to believe the Science-Based Healthcare Practices Act has been violated, it can issue a cease and desist order and impose a civil penalty. If the violator is recalcitrant, DOH can go to court seeking an injunction and the consequences escalate from there. Of course, the alleged violator can dispute the charges and have his day in court.
Conclusion
The Science-Based Healthcare Practices Act is an imperfect solution to the problem of legislative alchemy. It is preferable to avoid licensing practitioners whose tenets violate basic science. Given the impracticability of repealing over 100 separate state practice acts, imposing an evidence requirement for implausible practices offers — if I may — an alternative solution. The Act would also have the beneficial effect of curtailing the use of diagnostic methods and therapies which, although not implausible, have proven ineffective.
Suggestions for improvement are welcome.
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Reiki
Reiki (pronounced raykey) is a form of “energy healing,” essentially the Asian version of faith healing or laying on of hands. Practitioners believe they are transferring life energy to the patient, increasing their well-being. The practice is popular among nurses, and in fact is practiced by nurses at my own institution (Yale).
From reiki.org, we get this description:
Reiki is a Japanese technique for stress reduction and relaxation that also promotes healing. It is administered by “laying on hands” and is based on the idea that an unseen “life force energy” flows through us and is what causes us to be alive. If one’s “life force energy” is low, then we are more likely to get sick or feel stress, and if it is high, we are more capable of being happy and healthy.
Reiki is therefore a form of vitalism – the pre-scientific belief that some spiritual energy animates the living, and is what separates living things from non-living things. The notion of vitalism was always an intellectual place-holder, responsible for whatever aspects of biology were not currently understood. But as science progressed, eventually we figured out all of the basic functions of life and there was simply nothing left for the vital force to do. It therefore faded from scientific thinking. We can add to that the fact that no one has been able to provide positive evidence for the existence of a vital force – it remains entirely unknown to science.
But the discarded science and superstition of the past is the “alternative medicine” of today. There are many so-called “CAM” modalities that are based on vitalism, including Reiki. Reiki, in fact, is very similar to therapeutic touch, another energy healing modality that was popular among nurses, and although it continues to be used it is much less popular after 9 year old girl (Emily Rosa) performed an elegant experiment to show that it was nothing but self-deception. Reiki nicely moved in to fill the void.
The research on Reiki, and energy healing in general, is similar to that of many similar modalities – those with very low scientific plausibility that are not taken very seriously by medical scientists. The research is of generally low quality, poorly controlled small studies that seem designed to justify Reiki rather than see if it actually works. The most recently published study, for example, looks at anxiety levels and self-reported well being in cancer patient and finds, unsurprisingly, that patients feel better when they receive the kind attention of a nurse. The study is completely uncontrolled, and therefore of dubious value. One might consider such a study a complete waste of time and effort, as the results were never in doubt.
A 2011 review of reiki studies concluded:
The existing research does not allow conclusions regarding the efficacy or effectiveness of energy healing. Future studies should adhere to existing standards of research on the efficacy and effectiveness of a treatment, and given the complex character of potential outcomes, cross-disciplinary methodologies may be relevant. To extend the scope of clinical trials, psychosocial processes should be taken into account and explored, rather than dismissed as placebo.
In other words – existing research is a such poor quality we cannot draw any useful conclusion from it. I disagree, however, that this necessarily means that more research is needed. The low plausibility of using magical energy that has never been demonstrated to exist by medical science argues otherwise. Further, the last sentence is odd – it suggests the authors are trying to spin placebo effects into real effects. This is increasingly the strategy of alternative medicine advocates as it becomes clear that most of the modalities they favor do not work any better than placebo (which means they don’t work).
Reiki is now squarely in that camp. Published at about the same time as the review (and therefore not included in the review) is a well-designed study of Reiki where Reiki was compared to placebo Reiki (someone not trained in Reiki simply goes through the motions) vs usual care (no intervention). Not surprisingly, both the real Reiki and the sham Reiki groups did better on self-reported well-being than the no intervention group, but they were indistinguishable from each other. Therefore Reiki did not better than placebo. That means Reiki doesn’t work (at least in the regular world of science-based medicine).
The authors conclude:
The findings indicate that the presence of an RN providing one-on-one support during chemotherapy was influential in raising comfort and well-being levels, with or without an attempted healing energy field.
I notice the authors did not conclude “Reiki doesn’t work.” This is odd, given that both the treatment and placebo groups had the same effect on subjective outcomes. With regular medical interventions we conclude from this outcome that the treatment does not work. Imagine a pharmaceutical company concluding:
The findings indicate that taking a pill during chemotherapy was influential in raising comfort and well-being levels, with or without an active ingredient.
Therefore – taking pills is helpful. Let’s not fret about whether the active ingredient has any specific physiological effects. Reiki supporters appear to have taken a page out of the acupuncture handbook. If real and sham acupuncture are both better than no intervention (they argue), than acupuncture works, whether real or placebo.
This article by Edzard Ernst recently published in the Guardian also discusses this Reiki study. Ernst points out that, not only is it scientifically dubious to conclude from such studies anything other than the treatment does not work, it is ethically questionable to give such treatments as a placebo intervention. He writes
By insisting that patients must not be treated with placebos like reiki, scientists also advocate that they receive treatments that demonstrably work better that placebo. For instance, massage has been shown to improve the wellbeing of cancer patients beyond a placebo effect. If a patient receives a massage with empathy, sympathy, time, understanding and dedication, she would benefit from the placebo effect – just like the reiki patient – but, in addition, she would also benefit from the specific effect of the treatment that massage does and Reiki does not offer.
This is a critical point that I have been making also. Essentially, you cannot justify ineffective treatments simply because they provide a placebo effect. That is because effective treatments also provide the same placebo effect, but also provide specific benefits because they actually work.
I would argue that there are also many potential harms from convincing patients that unscientific treatments are effective because of their non-specific placebo effects. This is a deception, violates patient autonomy and informed consent, and sets them up to perhaps rely on ineffective “magical” treatments for non-self-limiting illnesses.
Let’s get back to the authors conclusions from the Reiki study – they argue that this study shows that the:
“presence of an RN providing one-on-one support during chemotherapy was influential in raising comfort and well-being levels…”
The part about “with or without an attempted healing energy field” is entirely irrelevant, and you could just as well substitute any ineffective or magical treatment for “healing energy” is that statement. But the first part of the conclusion is also dubious, in that we did not need this study to come to this conclusion.
It has already been well-established, to the point that it is appropriately taken as a given, that people feel better when they get the kind attention of someone else, especially if they are sick and that person is a health care professional with training and experience in comforting sick patients. We don’t need to keep studying this over and over again.
Kind attention plus X makes people feel better, just as well as kind attention alone. Great. We do not need to study this with every possible form of unscientific intervention filling in for X. And it is deceptive and unscientific to suggest that whatever fills in for X has some value because of this equation.
This is what I call the “part of this complete breakfast” fallacy. Even as a child I recognized that when a commercial advertised their pastries as being part of the complete nutrition offered by an otherwise nutritious breakfast, the pastries were nutritionally irrelevant. They added nothing, and the commercial was being deceptive in trying to make me think that they were nutritious simply by their proximity to a nutritious breakfast.
Reiki, acupuncture, homeopathy, and similar methods may be “part of this feel-good intervention,” but they are an irrelevant and superfluous part. It is the kind attention of the practitioner that matters – and only that attention. So such attention might as well be part of legitimate science-based interventions that also have a specific physiological benefit.
This suggests that the real purpose of the ritual of reiki, or other superfluous placebo ritual, is not to achieve a positive end for the patient but to give the practitioner a marketable “skill” (even though the evidence shows that someone without any such skill or training can get the same results). In a recent article about reiki making its way into hospitals, Kryak and Vitale write:
There is a growing interest among health care providers, especially professional nurses to promote caring-healing approaches in patient care and self-care. Health care environments are places of human caring and holistic nurses are helping to lead the way that contemporary health care institutions must become holistic places of healing. The practice of Reiki as well as other practices can assist in the creation of this transformative process.
I submit that if the goal is to make hospitals and other health care environments more nurturing, promoting reiki and similar modalities is that exactly wrong way to do it. They are tying a worthwhile goal to blatant pseudoscience, and therefore legitimate resistance to the pseudoscience will also cause resistance to the nurturing.
If we accept that health care environments can be improved by more time and resources being applied to patient comfort, reduced anxiety, and enhanced self sense of well-being – then let’s use what works, the time and attention of a caring provider. The placebo ritual that is reiki (or acupuncture, or whatever) is wasteful, distracting, and arguably unethical. It unnecessarily complicates efforts to improve patient caring by promoting demonstrable pseudoscience.
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Birth Control
From a message posted on Facebook:
Is the pill safe? The International Agency for Research on Cancer in a 2007 study made by 21 scientists reported that the pill causes cancer, giving it the highest level of carcinogenicity, the same as cigarettes and asbestos. It also causes stroke, and significantly increases the risk of heart attacks. Several scientific journals have stated that the natural way of regulating births through the Billings Ovulation Method has no side-effects, and is 99.5 % effective.
The Billings Ovulation Method (BOM) is a method of natural family planning where women are taught to recognize when they have ovulated by examining their cervical mucus, allowing them to avoid intercourse during fertile periods or conversely, to have intercourse during fertile periods when pregnancy is desired. We used to call people who used the rhythm method “parents,” but BOM is more reliable than older abstinence methods.
I’m a big fan of oral contraceptives. They contributed to women’s liberation by giving us a reliable method of planning, delaying, or avoiding pregnancy. They also have medical uses that go beyond contraception. Birth control pills (BCPs) have had such an important impact that they are known as simply “The Pill.” We have always known they were not 100% risk free; but we also know they are less risky than pregnancy itself. There are other methods of birth control; but they are generally less effective and less convenient. For those who want permanent solutions, tubal ligation and vasectomy are available; but even they have occasional failures. What does science tell us about the effectiveness and safety of BCPs as compared to other methods?
Effectiveness
According to the Wikipedia entry, the Billings Ovulation Method has a failure rate of 0-2.9% with perfect use and 1-5% with typical use. (They cite the original references for these figures). The corresponding numbers Wikipedia gives for “the pill” are 0.3% and 8%. The American Congress of Obstetricians and Gynecologists’ numbers for the pill are a bit less optimistic: they say “With typical use, about 8 in 100 women (8%) will become pregnant during the first year of using this method. When used perfectly, 1 in 100 women will become pregnant during the first year.”
A handy table on the FamilyDoctor website compares the failure rates of various birth control methods. It lists periodic abstinence methods as having a 20% failure rate, but that includes the less effective rhythm methods as well as the methods based on mucus examination.
Cancer? It Causes Some Cancers and Prevents Others
Information on cancer and oral contraceptives can be found here. There is an increased risk of cervical cancer, but most cases are related to HPV infection, so hopefully the new vaccines will eliminate much of that risk. There is an increased risk of liver cancer in low risk populations but not in high-risk populations. The risk of breast cancer may or may not be slightly increased: studies do not agree.
On the other hand, the pill clearly reduces the risk of uterine and ovarian cancers. And a meta-analysis found that the risk of colorectal cancer is also decreased.
The magnitude of these risks is small. I couldn’t find any information about overall cancer risk: whether the increase in some types of cancer outweighs the decrease in others.
What the IARC Really Said
According to the Facebook poster, the International Agency for Research on Cancer (IARC) said oral contraceptives were as carcinogenic as cigarettes and asbestos. That’s not what the IARC said at all. It does classify estrogen/progesterone in the same group 1 category as cigarettes and asbestos, but all that category means is that there is sufficient evidence to prove carcinogenicity in humans. It does not in any way imply that oral contraceptives are as carcinogenic as cigarettes and asbestos: they aren’t. And the IARC entry clearly states
There is also convincing evidence in humans that these agents confer a protective effect against cancer in the endometrium and ovary.
Other Risks
BCPs increase the risk of deep venous thromboembolism and ischemic stroke. There is disagreement over whether they increase the risk of myocardial infarction. The absolute risk of all these conditions is low. It is greater in smokers and in those with other risk factors, and it is lower for the newer low dose BCPs.
The ACOG has prepared an excellent patient education pamphlet listing all the risks, benefits, side effects, and contraindications. It concludes:
The pill is a good choice for women who may want to get pregnant later. It is a safe and effective way to prevent pregnancy. It is easy to use, convenient, and reversible. The pill may protect against some cancers. Some benefits of pill use last months or years after you stop taking it. For almost all women, the benefits of pill use outweigh the risks.
Benefits
Critics of hormonal contraception fixate on the risks, but there are also a number of health benefits. The ACOG patient information pamphlet explains that BCPs reduce the risk of
- Cancer of the uterus and ovary
- Ovarian cysts
- Pelvic infection
- Bone loss
- Benign breast disease
- Symptoms of polycystic ovary syndrome
- Anemia (iron poor blood)
- Ectopic pregnancy
- Acne
They also
- Help to keep periods regular, lighter, and shorter and reduce menstrual cramps
- Reduce symptoms of endometriosis and fibroids
- May help with migraine headaches and depression.
- Can be used to schedule periods to avoid an inconvenient time (i.e. a wedding).
Other Options
There are many other birth control options: condoms, diaphragms, other hormone delivery methods like cervical rings and injections, IUDs, spermicides, periodic abstinence methods, and therapeutic abortions. Some methods have the additional benefit of protection against sexually transmitted diseases. Some methods require specific actions at the time of intercourse, which some people object to as interfering with spontaneity. The periodic abstinence methods have the disadvantage of requiring periodic abstinence.
I remember reading years ago (the reference is long gone and I don’t know if the information is still valid) that when all factors were considered including the risks from pregnancy itself when contraception fails, the safest method of birth control was to use condoms and do therapeutic abortions when they failed. That resulted in statistically less morbidity and mortality overall than any other method. Of course there are other considerations that make this a less than ideal option. Emotions and religion create a lot of bias in the area of birth control. I suspect some people who reject oral contraceptives as “unsafe” might be quite willing to take other medications that have a similar safety profile but are not connected to ideological concerns.
Conclusion
BCPs are not risk-free, but the Facebook poster was wrong: their risks can’t be compared to the risks from cigarettes and asbestos. There are other good alternatives that some individuals may prefer for various medical and non-medical reasons. For any method of birth control, the risks must be weighed against the benefits. Pregnancy itself is far riskier than any method of pregnancy prevention.
The safest, most effective method of birth control is orange juice. You may ask “Before or after?” The answer is “Instead of.” Most women and their partners would not consider that a satisfactory option.
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Cranial Osteopathy in Dentistry
Editor’s note: Having just submitted a major grant on Friday and then having had to turn around and head to an NIH study section meeting today in Bethesda, I just didn’t have the time to produce something up to the usual standards of SBM for today. (And, being managing editor, I should know what’s up to the usual standards of SBM; what I started to write wasn’t it. Trust me on this.) Fortunately, Dr. Grant Ritchey and Dr. Steve Hendry, two skeptical, science-based dentists, did submit something up to SBM’s usual standards. Even better, since we’ve been having a number of requests for posts involving dentistry, it seemed like a perfect time to publish their first contribution to SBM and see how our readers like it. Maybe next time around, I’ll have them update the “state of knowledge” regarding amalgams.
Form follows function, as the old saying goes. Nowhere in the human body is this adage more fitting than in the oral cavity. In less than two generations, the practice of dentistry has evolved from basic pain relief and function-based procedures (such as extractions and fillings), into today’s practices of complex cosmetic rehabilitation, orthopedic and orthodontic management of the teeth, jaws, and facial structures, replacing missing teeth with dental implants, and treatment of sleep apnea and temporomandibular joint (TMJ) disorders, to name but a few. With such rapid progress, it is to be expected that for every science based advance made in our field, there are just as many claims that are either dubious in their evidential support or outright pseudo-scientific or anti-scientific nonsense.
In this article, we’ll be taking a look at the roles that health care practitioners such as chiropractors, osteopathic physicians, and physical therapists, are attempting to play in the dental field. We will also see how well-meaning dentists have been trained in and apply their pseudo-scientific principles in their dental practices. In particular, we’ll be examining Cranial Osteopathy (also known as Craniosacral Therapy or Cranial Therapy) in the management of the dental patient, the purported benefits claimed by practitioners of cranial osteopathy, and the quality and quantity of evidence for this type of treatment in the scientific literature.
Basic Skull Anatomy
The human skull is made up of some eight cranial (head) bones and fourteen facial bones. These bones help protect the organs of vision, hearing, taste, equilibrium, and smell. They also provide attachment for muscles that move the head, control facial expressions and chew our food. At birth, the spaces between the cranial bones- called fontanelles – are wider and more elastic, allowing the infant to pass through the birth canal and later permitting brain growth in the first few years of life. In humans the lateral fontanelles close soon after birth, the posterior fontanelle generally closes several months later, and the anterior fontanelle may remain open for three years.
By early childhood, the cranial bones become tightly interlocked in a zig-zag, zipper like pattern (illustrated nicely here) that renders them immovable in a macroscopic sense, although each suture (called a synarthrosis if you want to impress your friends at parties) has a very slight amount of flexibility- 10-30 micrometers on average (1 micrometer = 1/1000th of a millimeter or approximately 4/100,000ths of an inch). These sutures fill the minuscule space between the cranial bones, essentially stitching them together with dense, strong connective tissue fibers called Sharpey’s fibers.
Tenets and Scope of Cranial Osteopathy
Cranial Osteopathy was invented by William G. Sutherland D.O. around 1900 when, while viewing a disarticulated human skull, he noted the way some of the skull bones were: “…beveled… like the gills of a fish… indicating articular mobility… for a respiratory mechanism.” Note that we said “invented” rather than “discovered,” as this discipline was indeed invented from whole cloth, based upon the happenstance similarity in the appearance of a skull bone and the gills of a fish, which he then superimposed on his 19th century osteopathic ideology. (Imagine what he would have come up with had he instead noted the similarity between the uvula and the male genitalia!) Sutherland claimed, and adherents of Cranial Osteopathy hold, that the cerebrospinal fluid (CSF) has an inherent rhythmicity, which he likened to the tides of the ocean. He called this the “Primary Respiratory Mechanism (PRM)”, often referred to today as “Craniosacral Rhythms.” According to Osteopathic principles, the PRM underlies all of life’s processes and begets vitality, form, and substance to all of a person’s anatomy and physiological processes. Any disturbance in the natural flow of CSF could cause illness and conversely, practically any illness could be prevented or cured by the physical manipulation of the cranial bones, “freeing up” the functional flow of the CSF. Towards the latter part of his life, Sutherland believed that he could sense a “power” which allowed corrections to occur from inside his patients’ bodies without having to provide any physical manipulations. This has come to be known as “biodynamic craniosacral therapy” or “biodynamic osteopathy”. See this overview of the scope of Cranial Osteopathy (“The Cranial Concept”) in their own words.
Of course, none of this imagery would be of any use without a therapy to sell, and osteopaths assert that they can fix what ails you through hands-on manipulation of your skull bones. As one practitioner’s website puts it: “As incredible as this may seem, we feel the bones move, the membranes pull, the fluids fluctuate, and even the brain undulate”. And woe unto the poor sap who suffers from a rigid-boned, lax-membraned, fluid stasisy, un-undulating brain! Practitioners of Craniosacral Therapy or Cranial Osteopathy claim that they can detect this secondary CSF pulse with simple palpation and distinguish them from a regular vascular pulse.
Cranial manipulations are performed in a variety of different ways depending upon the condition being treated and the philosophy and training of the practitioner. (See an overview of some of the techniques.) Some of them include range of motion therapies similar to what a physical therapist would do; others involve the supposed manipulation and movement of the cranial bones, using only digital (i.e. finger) pressure with a very light force.
The Cranial Osteopathic Academy, a component society of The American Academy of Osteopathy (AAO), described it thus:
Treatment is typically very gentle. Tissues are supported and allowed to change. Usually very little force is used during treatment, but at times some force may be necessary. Diagnosis and Treatment are said to blend into one another. As tissues change the physician learns more about their nature. As the nature of the tissue dysfunction is better understood, the therapeutic response deepens.
Each patient’s experience is unique. Some patients sense only a gentle touch, while others feel their body change immediately. Some patients simply feel a deep sense of relaxation, and others feel nothing at all. Most patients feel a distinct change following the treatment.
Though Cranial Osteopathy is very gentle, patients can occasionally experience some discomfort during certain stages of the treatment. When this occurs, it is simply a part of the healing process. As the treatment progresses, the discomfort subsides.
Although physicians practicing Osteopathy in the Cranial Field will work anywhere on the body, they may find it important to diagnose and treat the head. Though styles of treatment may vary, the osteopathic physician will primarily focus on the body’s “mechanism” – the body’s natural striving for health and normal function.
According to Dr.Sutherland, within each patient there is great wisdom, an inner physician, a wise all-knowing force that is the source of all healing. In his own words: “Allow physiologic function to express its own unerring potency rather than apply blind force from without.”
Cranial Osteopathy and its variants make a number of imaginative leaps from histological starting points to therapeutic endpoints. From the slight (micrometer) flexibility of cranial sutures, and the slight-but-measurable fluctuation in CSF pressures, practitioners infer that the brain and spinal cord undulate rhythmically “like a jelly fish, coiling and uncoiling” which is critical for health.
Dental Applications of Cranial Osteopathy
Gradual movement of teeth within bones, and gradual orthopedic movement of facial bones themselves, are familiar to all dentists who do orthodontics. Dentists performing orthodontic treatment utilize various appliances to expand the palate (palatal sutures don’t normally fuse until adolescence) and move teeth within the jawbones. Further, the treatment of TMJ disorders has typically been in the realm of the dentist, involves the articulation of cranial bones in the scope of treatment (the mandible and the temporal bone), so the Osteopathy belief system would seem a natural fit to dentistry, especially in these areas. And sure enough, Osteopathy has colonized the dental profession. We’ve seen expensive dental continuing education courses with “Cranio-”, “Sacro Occipital Therapy” and “Chiro-” in their names that graft Osteopathic principles onto dentistry to create whole new, untapped disciplines to market.
Websites promoting these dental applications of Cranial Osteopathy claim to teach amazing new skills to dentists, including how to “free up” and move facial bones around, by hand, in minutes using only fingertip pressure. Additionally, in almost every case, these dental courses provide a gateway to other, more garden variety forms of CAM: nutritional supplements, detox, immune system boosting, nervous system balancing, and so forth. For the dentist, taking one of these courses is the first step in going “down a rabbit hole” into CAM-land – a metaphor that devotees enthusiastically embrace and frequently use.
An important point to reiterate here is that the emphasis in the dental application of cranial osteopathy is not merely to treat illness or facilitate the flow of the CSF as in “regular” osteopathy; it claims to actually bodily move the facial and cranial bones to more ideal positions to improve orthodontic and TMD outcomes. Cases are shown where overall changes in facial structure and the occlusion (i.e. the bite) are alleged to have been changed by as much as a half of an inch or more by cranial manipulation alone. Of course, these are case studies with little to no supplementary documentation (radiographs, CT scans, etc.) available for an objective reviewer to confirm the claims. We have yet to see a well-documented, objectively presented case study in the medical or dental literature which adequately demonstrates the validity of the treating practitioner’s claims, although one would think that after decades of the existence of their treatment modalities, such evidence would be plentiful, substantive, and readily accessible to the health care community.
Credibility as a Dental Treatment
For Cranial Osteopathy to be viable treatment, there needs to be good evidence anatomically and histologically that the sutures are indeed movable (by hand, no less) to a significant degree, and evidence that doing so is therapeutically beneficial. Neither appears to exist. Although Cranial Osteopathy can provide a modicum of basic research to support its claims, it falls far short of what is needed to establish a scientific foothold in the dental-medical community. Osteopathic applications are woefully lacking in any substantive research but instead rely on anecdotal evidence as the foundation of its validity and applicability. See the excellent overview of Cranial Therapy at Quackwatch.org.
Evaluating the literature, minute movements of the cranial bones appear to be possible (in the micrometer range as stated above) — but not the large rearrangements of bones that practitioners claim to make with hands-on manipulation. It is dubious that a practitioner can feel distortions in cranial bones that the most sensitive neurophysiological instruments cannot.
Moreover, even if an Osteopathic therapist could detect abnormalities in the skull, there appears to be no credible evidence linking small movements at cranial sutures to beneficial health outcomes. As a scientific principle, this is nothing more than wishful thinking and resembles faith healing more than evidence based medicine. The therapeutic claims, research protocols, treatment goals, and definitions of what constitutes solid medical evidence are as flexible as the cranial bones they purport to manipulate.
Cranial Osteopathic adherents predictably scold their critics as being closed-minded and unwilling to learn, or worse, a shill for the Dental Industrial Complex. But we like the old adage about staying open-minded, but not so open that your brain falls out. The really surprising (and disturbing) thing to us is the number of bright, conscientious, and highly-trained dentists we see being drawn to courses in Cranial Osteopathy, and in many cases buying into the smorgasbord of alternate-medicine courses offered as side dishes at the cranio-dental table. If there’s harm in the Cranio-dental movement, besides a lot of money wasted by dentists on dubious courses and by patients on dubious treatment, it may be that it seems to be a particularly attractive gateway to more bizarre alternate treatment philosophies – one that seems to appeal to surprisingly smart and educated dentists. By granting dentists a license to practice, the public trusts us to apply evidential knowledge to the management of their dental problems. This implies that we must critically examine new hypotheses, decide if there is rational evidence for them, reject the pseudo-science, and apply the knowledge that sifts through for the benefit of the patients we serve.
Post Script: This is our first article in what we hope will be many to come on dental-related topics. We would love to hear from you, the fine readers of the Science Based Medicine Blog. If there are topics you would like to see addressed, or if you have any questions, comments, or critiques, please feel free to email us at HYPERLINK “mailto:skepticaldentist@gmail.com” skepticaldentist@gmail.com.
Dr. Grant Ritchey received his Bachelor’s degree in Human Biology from the University of Kansas in 1982, and his Doctor of Dental Surgery degree from the University of Oklahoma in 1986. He lives in Kansas City, is married, and has two grown daughters. Since 1986, he has maintained a general dental practice in Tonganoxie, Kansas, and was awarded a Fellowship in the Academy of General Dentistry in 1998. Currently, he is working toward his Masters in Education Degree from the University at Buffalo in the Science and the Public program, with an emphasis on the prevalence of alternative medical practices in dentistry.
Dr. Steve Hendry, BSc DDS FAGD, completed an honours degree in Genetics at the University of Western Ontario before deciding to be a dentist when he grew up. He spent summers working in a corn cytogenetics research lab through dental school. Since graduating in 1981, he’s maintained a general dental practice. Steve has always been fascinated and appalled at the scarcity of critical thinking skills in society and, increasingly in his own profession. He is particularly proud of having attained the status of “closed minded” in the eyes of some of his woo-friendly peers.
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Crislip and Atwood at Boston Skeptics in the Pub, Wednesday, 10/19
Look here for details. We’ll talk about acupuncture for not too long, and then hang out and drink. Hope to see you there!
KA
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New Data Centers, Barbara Streisand & “Da Bobby G”
Dealing with jet lag, unfamiliar surroundings, foreign currencies and different languages just begins to describe my hectic life over the past two months. We’ve been in overdrive, building out SoftLayer’s Singapore and Amsterdam data centers in weeks (rather than months).
Our “Go Live Crew” of 16 dedicated SLayers has been working ’round the clock to make sure everything is up and running on time. The biggest challenge has been building out both data centers simultaneously … With the “Go big or go home” mindset, when we decided to go international, we went all in. Our growing customer base of 23,000 won’t stand still, so we need to deliver, whether it be through innovation or expansion. In less than 60 days we’ve been able to add 31,000+ servers to our network platform, bringing our unique cloud, dedicated and managed hosting solutions closer to our customers around the world.
This accomplishment has been something of a “miracle,” and I really need to shout out to my team members on the GLC. Putting in 16-hour days and working weekends while still finding time to go out on the weekends (Jägermeister and Red Bull have been sampled at many a fine pub) has made us a pretty close-knit family. The old “work hard, play hard” saying is an understatement when it comes to the SoftLayer team.
If we’re ever dragging a bit in the morning, we can always rely on Duck Sauce to get our pulses racing again by the time we get to the data center. With such a full work schedule, we become creatures of habit, and “Barbara Streisand” is only one example of a staple for the crew. Our daily consistency has even carried over into meal time: My favorite luncheon spot in Amsterdam even named a sandwich after me – Da Bobby G Meat Sandwich. Apparently the combination of meatballs, salami, ham and (a smothering of) ketchup on a bun is not a common order at this establishment, so my innovation needed to be recognized. Nutritional considerations aside, this is one fine sandwich:
I’ve been on the road for a while now, and these are just a few memories I’m taking with me. Jumping around between three continents has definitely had its challenges, but with a great team of focused SLayers, we’ve been getting the job done. I’m proud to have had a hand in making our international aspirations a reality, and I know that even though this has already been an unbelievable adventure, we’re just getting started.
-Robert
Adding ‘Moore’ Storage Solutions
In 1965, Intel co-founder Gordon Moore observed an interesting trend:”The complexity for minimum component costs has increased at a rate of roughly a factor of two per year … Certainly over the short term this rate can be expected to continue, if not to increase.”
Moore was initially noting the number of transistors that can be placed on an integrated circuit at a relatively constant minimal cost. Because that measure has proven so representative of the progress of our technological manufacturing abilities, “Moore’s Law” has become a cornerstone in discussions of pricing, capacity and speed of almost anything in the computer realm. You’ve probably heard the law used generically to refer to the constant improvements in technology: In two years, you can purchase twice as much capacity, speed, bandwidth or any other easily-measureable and relevant technology metric for the price you would pay today and for the current levels of production.
Think back to your first computer. How much storage capacity did it have? You were excited to be counting in bytes and kilobytes … “Look at all this space!” A few years later, you heard about people at NASA using “gigabytes” of space, and you were dumbfounded. Fastforward a few more years, and you wonder how long your 32GB flash drive will last before you need to upgrade the capacity.
As manufacturers have found ways to build bigger and faster drives, users have found ways to fill them up. As a result of this behavior, we generally go from “being able to use” a certain capacity to “needing to use” that capacity. From a hosting provider perspective, we’ve seen the same trend from our customers … We’ll introduce new high-capacity hard drives, and within weeks, we’re getting calls about when we can double it. That’s why we’re always on the lookout for opportunities to incorporate product offerings that meet and (at least temporarily) exceed our customers’ needs.
Today, we announced Quantastor Storage Servers, dedicated mass storage appliances with exceptional cost-effectiveness, control and scalability. Built on SoftLayer Mass Storage dedicated servers with the OS NEXUS QuantaStor Storage Appliance OS, the solution supports up to 48TB of data with the perfect combination of performance economics, scalability and manageability. To give you a frame of reference, this is 48TB worth of hard drives:
If you’ve been looking for a fantastic, high-capacity storage solution, you should give our QuantaStor offering a spin. The SAN (iSCSI) + NAS (NFS) storage system delivers advanced storage features including, thin-provisioning, and remote-replication. These capabilities make it ideally suited for a broad set of applications including VM application deployments, virtual desktops, as well as web and application servers. From what I’ve seen, it’s at the top of the game right now, and it looks like it’s a perfect option for long-term reliability and scalability.
Native Rank: Tech Partner Spotlight
Welcome to the next installment in our blog series highlighting the companies in SoftLayer’s new Technology Partners Marketplace. These Partners have built their businesses on the SoftLayer Platform, and we’re excited for them to tell their stories. New Partners will be added to the Marketplace each month, so stay tuned for many more come.
- Paul Ford, SoftLayer VP of Community Development
Scroll down to read a guest blog from Native Rank. Native Rank provides an effective solution for improving your visibility across search engines, social networks and web maps. They are a full-service search and advertising solution for small to large businesses both on a local and national level.
More Information
Company Website: http://nativerank.com/
Tech Partner Marketplace: http://www.softlayer.com/marketplace/nativerank
Ranking Well != Being Well Ranked
There is a common misconception in Search Engine Optimization: That if Company A was just on the first page for some random keyword, the sky would open up and leads would fall from the heavens. This is not always the case, and a better place to start the process of deciding what Key Words will be most effective for a client to rank for can be assessed in 3 easy steps:
- In depth keyword analysis for terms that your customers actually use to find a business like yours. If you specialize in DUI law, keywords structured around your area of expertise will lead to a higher quality of lead than the search term, “Denver Attorney.”
- Be realistic about who your competitors are and find where they are ranking organically. There is no need to reinvent the wheel. This will give you a good road map for what your competitors are doing and they are creating success.
- If you have a physical location make sure your local maps listings for Google, Yahoo and Bing are optimized and Owner Verified. The Search Engines want to show your business to Searchers that are in your Geographic area..Please let them!
Once you have gone through those three easy steps, make sure that the SEO company you are working with has the same expectations that you have for your business. Targeted success metrics and milestones need to be at the core of your SEO strategy. Ranking for 50 Keywords that bounce at 90% will not result in more customers through your door. It is very important that the SEO firm you use has your business objectives in mind. If not you may find yourselves three or six months down the road having a very uncomfortable conversation about what success is.
If you’ve never made a concerted effort into SEO and SEM strategy, we’d be happy to share some of the tools we’ve developed to get you ranking well whether you consider yourself a local business or a national one. Head over to http://nativerank.com/ to see a few of our products in action and learn a little more about our service.
-Winston Cook, Native Rank
Taking Multitasking to a New Level
Is it possible to be in 3 places at once?? For SoftLayer it is! Last week was an extremely busy one for the SoftLayer team. SLayers from the marketing and sales teams were dispersed to cover three different trade shows in two separate cities where we’d meet a few thousand soon-to-be SoftLayer customers.
I attended Web 2.0 Expo in NYC – a great event where I was able to once again demystify the SoftLayer Switch Ball and explain the awesomeness of SoftLayer. Nothing too crazy to report from the expo floor, but we did have one interesting experience outside of the event where we witnessed a man sleep while standing up. We don’t know how he was able to sleep for over two hours without falling over, but his execution was impressive:
While I was in New York City, cPanel Bootcamp was happening closer to home in Austin, Texas. From what I hear, a second annual rocket war broke out, and our booth was rushed by attendees looking to stock up on ammo.
Just down the street from the cPanel conference, GDC Online was up and running in the Austin Convention Center. This was another awesome event for SoftLayer and once again the Server Challenge was a huge hit:
Congrats to Anthony Pecorella for winning with a time of 1:00.84! We know you’ll enjoy your new iPad.
After both show floors closed, attendees from both cPanel Bootcamp and GDC Online joined us for some drinks, food and retro games at Maggie Mae’s on Sixth Street. Notable attendees included Mario, Princess Peach and our very own Jeff Reinis who happens to be a 1983 Pac-Man record holder!
If you didn’t have a chance to join SoftLayer, CoreSite and TeliaSonera at the Time Warp Retro Gaming Party, you can live vicariously via Flickr:
Thanks to everyone who worked so hard to make sure these three events went off without a hitch, and thanks to all of you who stopped by and said hi! We hope to see you all soon at one of our upcoming events: http://www.softlayer.com/Media/event-schedule
-Summer
Why Don’t You Work Here Yet?
I started my career with SoftLayer in March 2011 as a Server Build Technician, and after a few short months, I can safely say that coming here was one of the best moves I have ever made in my life. I have worked in a number of different jobs ranging from retail to shipping, but in my heart, I always knew I wanted a career in computer technology. SoftLayer made that dream come true.
When I started, I felt a bit overwhelmed with the amount of information I had to learn all at once. That feeling quickly subsided during the first week as I realized how the work environment and culture is built on employees who take great pride both what they do and the knowledge they are able to pass on to newcomers. I knew I was in good hands. I felt like I was a part of an elite group of intelligent, inspiring, funny, energetic and down to earth people.
Through the interactions I’ve had with my direct coworkers, my knowledge has grown tremendously, and I feel more confident in meeting and exceeding the expectations and responsibilities in front of me. The original SoftLayer culture is alive and well thanks to the efforts and example of the management team, and it doesn’t take long to notice that this company has a passion for customer service, and we strive to be the very best we can be. Because of the encouragement and optimism I have been given, I see a bright future for me here.
As our operations expand, I can’t help but get excited for the success in store for the business, our team and our customers. We’re ready to embrace new challenges, and though the tasks seem daunting, I know our team can handle them easily. I take great pride in my work, and I’m quick to tell the SoftLayer story to anyone who will listen. The company motto is, “Innovate or Die,” and every employee – from Dallas to Amsterdam to San Jose to Singapore – lives and breathes that motto daily. We’re pushing the limits of what a “hosting company” can do, and we’re having a lot of fun doing it.
I feel honored to say that I am a part of the SoftLayer family, and if you’re in the market for a new job for an awesome employer, you should head to SoftLayer Careers to find which of the 50+ positions you’d fit so you can join us in Dallas, Houston, San Jose, Seattle, Singapore, Amsterdam or Washington, D.C.
We are SoftLayer!
-Anthony
SoftLayer, The Texas Rangers & The World Series
At the beginning of the baseball season, we gave away tickets for a lucky customer to see a Texas Rangers game, and as a result of that generosity, the Rangers thought it fitting to make it to the World Series. Well … our little giveaway may not have had anything to do with their success, but we like to think our support helped a little.
Understanding that we have customers and employees who are die-hard St. Louis Cardinals fans, I don’t want to turn anyone off with this blog post, but with all of the buzz in the air about the World Series coming back to Arlington this year, I started thinking about the Top 10 Ways SoftLayer is Like the Texas Rangers:
- Secret handshakes / fist bumps.
- Have a no “I” in “Team” mentality … In fact, there are no I’s in “Texas Rangers” or “SoftLayer.”
- Teams’ leaders (i.e. coach and the CEO) are … um … charismatic (to say the least).
- Come ready to play on any day that ends in “y.”
- Strong lineups all the way through.
- Texas is home, but both teams do amazing jobs “on the road.”
- Both have Michaels who like pink.*
- Both have Louisville Slugger bats … The Rangers’ bats do great things, while SoftLayer’s bats are given to recognize employees that have done great things.
- Support is awesome from the customers (fans) to the back office to the team on the field making plays.
- Champions of the World, baby!!**
* Apologies to Michael Young, as this statement may not be true as applied to him. Each of my blogs to date has a veiled (or obvious) reference to our CFO, and it was very difficult to think of how to incorporate this reference in a blog dealing with the Texas Rangers, so I may have taken undue liberties for which I apologize.
** The aspirations associated with that last comparison may have strayed me from an unbiased comparison. 
Advice for the Non-Experienced Tradeshow Traveler
SoftLayer attends 60+ tradeshows a year. That may not sound like much too some people, but when it means you’re only home for six days in a given month, it’s pretty daunting. Some think that going to a tradeshow is a “free” min-vacation, but in reality it’s exhausting work. You’ll get lucky at a few shows where the booth time is only 4-6 hours, but most of the time, you’re on the hook for 8 or 9 hours. You never know how much you use your leg muscles by just standing until you do it for nine straight hours. After being on your feet for that long, the first thing you want to do when the show closes is go to dinner just so you can sit down. Now think about doing this for three or four days in a row, and it doesn’t sound like a vacation anymore.
Before I turn you off tradeshows altogether, I should admit that they are actually quite fun if you’re a people person. I love getting to meet new people and show them what SoftLayer has to offer. It’s a rewarding experience to see that light in someone’s eyes who has never heard of SoftLayer and then finds out how we can make their business better. I can’t help but think to myself, “Yeah, we are kind of a big deal.” 
Given my extensive experience in the conference and tradeshow realm, here are a few key pieces of advice for the non-experienced SoftLayer tradeshow traveler (adjust for your brand as necessary):
Attire
- Guys should wear black slacks with a polo or button down. For the more casual shows, nice jeans (no rips, tears or holes) and any kind of SoftLayer shirt is fine.
- Girls should wear black slacks or a black skirt with a polo or button down … And now you have the option of a SoftLayer dress.
- It’s always a good idea to wear slacks the first day to “test the waters” of the attire for the show. After that, you can plan your next day’s attire accordingly.
- Always wear black shoes. Girls do NOT wear high heels … You will regret it 30 minutes into the first day. An great alternative for the ladies are black flats, these will look great with pants, a skirt, or a SoftLayer dress.
- Sometimes it gets extremely cold in the conference hall, so I suggest bringing a jacket – even if it’s 110 degrees outside. When wearing a jacket over your attire, make it one of the branded SoftLayer jackets – a SoftLayer logo should be visible at all times so attendees know you’re not a random stranger in the SoftLayer booth.
Behavior
- I know how easy it can be to get carried away when other attendees get a little wild, but that is NO excuse to be late, completely absent or operating at less than 100% when you get to the booth the next day.
- You should always have a smile on your face when talking with attendees. You’re talking about great stuff when you’re talking about SoftLayer, so you should be happy to share it with the next potential SoftLayer customer.
- This should go without saying, but there should be NO cursing, yelling or arguing with anyone at the booth.
Last but not Least
The number ONE rule for the non-experienced traveler: ALWAYS, ALWAYS, ALWAYS know your stuff before going to a tradeshow. Nothing is more embarrassing for your colleagues (or SoftLayer in general) when you are asked a simple question about what SoftLayer does and you do not know. If you do not know something, ask a colleague or simply look on our website. We have plenty of information there and numerous datasheets that explain in detail the products and services SoftLayer offers.
-Natalie
Environmental Advocate for Clean Water Action
Photo Credit: Local Government Federal Credit Union
The official title of the position was Environmental Advocate for Clean Water Action. It was an environmental policy and advocacy job and I worked there for a little over a year. Previously, I worked in outdoor retail stores and have a degree in Outdoor Education, so at that point I had approximately five years of experience in the field. To describe myself, I would be passionate, dedicated and reliable.
I am a white male and in this position, this would sometimes help or hinder me depending on the area I was working. I do not believe that I have ever had a specific incident where there was outright discrimination towards me.
As an Environmental Advocate, I was responsible for going door to door and talk with people about a particular environmental issue. The goal was to get support for the cause through signatures and also get donations for Clean Water Action. It involved a lot of walking and required you to have a thick skin when talking with some people. A common misunderstanding people had was that they often did not believe they could make a difference simply by signing a petition or donating a small amount of money.
The job satisfaction for this position was usually a 6. It was rewarding when you got to speak with a person who was behind the environmental movement or when you were able to open someone’s eyes to the issues. Since it was essentially a sales job, it was quite demanding and stressful at times. Complete confidence is needed to succeed in this.
The environment has always been important to me, so this was more than a job. It was a chance to change the way people think and make a difference. If I had more of a knack for sales at that point in my career, I may have stayed longer in this position.
There is nothing particularly unique about my situation.
I first fell in love with the outdoors at summer camp as a child. I worked at camps for many years, and then went to college for Outdoor Education. Once I got out of college, I thought I was going to find the perfect job where I would be a Naturalist and then settle down from there. Reality snuck in and I was searching for something in the environmental field. This position was open in the city I was looking to live in, so it was the perfect fit. A career path is usually winding and interesting, so I would honestly not change anything with my particular path.
Rejection was a difficult lesson in this particular position. Learning to accept this and simply move on to the next person is all that you can do. After getting a less than great reception from some people on the first day of work, I realized that it is a part of the job.
The most important thing that I have learned is that no matter what position or job is held, it is always best to do the job to the best or your ability.
Since this position involved going door to door, you would encounter a lot of interesting people every day. The strangest thing to happen would have been when I was invited in a person’s house and he proceeded to tell me about his preparations in the event there was some sort of environmental disaster. He was a bit of an extremist, but did support the cause I was working with.
The reason for going to this job each day was simply because it was making a difference in the environment. On those days where I was able to convince a person to care more about the environment, I felt proud and successful.
With this position, the challenge was always to make the daily and weekly quotas. It was basically a sales job and this was often quite difficult.
When sales are difficult, this job could be quite stressful. I always wanted to perform to the best of my ability and some days were harder than others. It was a day shift job with decent hours, so I was able to maintain a decent work-life balance. Once I was home for the day, I was done working and focused on my home life.
The salary range varies quite a bit. It was an hourly position that started at $12 an hour, but there were bonuses on top of that based on the performance each week. The salary was fine for a single person, but could not support more than that.
There was ample vacation time. I was usually able to take at least five days off for a small vacation each year.
The main skills that are needed would have to be an ability to sell to people and be comfortable with speaking in potentially difficult situations. The only other requirement would be a love for the environment and the ability to get behind a cause. In this position, a particular educational background was not necessarily more beneficial than another.
For a person considering this line of work, I would say that it takes determination to succeed to do this as a long term position. It can be stressful and it takes the right person to do well at it.
Since working in this position, I have moved up in the ranks and have been working in management positions. In five years, I would like to see myself as a high level manager.
This is a true career story as told to AllEnvironmentalalJobs.com and is one of many interviews with environmental professionals, which among others include an environmental scientist and an environmental operations manager.