On the wing

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Kittiwakes having a bumper season - young have started to fledge

Nearly there - an Arctic Tern youngster
Wednesday 29th June comments: Another glorious day on the islands and the action continued as a few more Kittiwake youngsters took to the wing for the first time. At present, it appears to be another cracking year for Kittiwakes, our third consecutive year we've enjoyed a bumper crop of young (following a ten year decline).

It's not just the cliffs nesters which are reporting a good season as the first Arctic Tern fledger is only days away from flying and within a few weeks, we'll hopefully be reporting another successful year. A quick study yesterday revealed that two youngsters from the same nest were fed sixteen times in ten minutes - now that is rapid foraging!
Wader passage is gradually increasing with over 200 Knot present on Longstone whilst 23 Black-tailed Godwits flew west over the islands yesterday. Soon we'll have return autumn passage migrants and then the fun will really start!

Storm clouds lifting

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Happy family; Arctic Tern brood (Ciaran Hatsell)

Ready to fledge Cormorants (Ciaran Hatsell)

Moth trapping season - a Ghost Moth (Will Scott)

Adult Black Tern in roost (Andy Denton)

A passing Tall ship (Will Scott)

Tuesday 28th June comments: The Farnes is still just recovering from last weeks sad events and for many, the place will just never be the same. Despite the passing of Billy Shiel, his name will be forever be linked with the islands as his boat company continues to bring thousands of visitors to witness the spectacular seabird reserve that is the Farne Islands.

It’s over a week since the last update and so much has happened. We’ve now got Kittiwake, Puffin, Shag and Cormorant fledglings to boast about whilst the first Sandwich and Arctic Tern chicks are ready to take to the wing. The season continues to produce mixed weather but the results of the breeding season appear to indicate a very successful on. At time of writing, Arctic Terns are fledging (on average) two chicks per nest (not an annual occurrence) although predation by large Gulls is still having an effect in some areas. Large numbers of Guillemots and Razorbills have now gone whilst Eiders have almost completed their breeding season for another year.

The Farnes continues to bring surprise visitors as we discovered another Spoonbill on 15th June whilst an adult Black Tern was seen over several days last week. Roseate Terns have not bred again this year but a pair continue to show well on a daily basis by the main jetties on Inner Farne.

Bustard Island

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bustard-island-14Canadians have a knack for giving their islands unique names and they don’t disappoint with Bustard Island.

However there is much more to this property than its unusual name. This rare listing offers the ultimate in privacy and beautiful surroundings. The Bustard island group is well known as one of the most scenic and unspoiled island groups of Georgian Bay.

The main cottage is of cedar log construction with pine floors. It features a living room with a stone fireplace, a sun room with scenic south view, a spacious kitchen with a propane stove and fridge, a 2-piece washroom, and a large bedroom.

There are 2 cedar log cabins, well spaced apart on the island.

The island is located in a sheltered bay, ideal for float planes to land, even on windy days, and has deep water docking for sailboats and cruisers. The Bustard Islands are a dream come true to explore the countless islets and bays by kayak or canoe…

For more information on this property visit Private Islands Online.

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Floating Island Pool

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pool-concept-10-537x357On islands like Manhattan space comes at a premium and often large recreational centres like public swimming pools are the first things to be sacrificed. However if everything goes “swimmingly” Manhattan could soon become home to one of the worlds first floating swimming pools. Part swimming pool, part man made island, this floating pool concept could be providing summer respite to heat weary New Yorkers as soon as next summer pending final approvals. The best part of the project is it is completely sustainable taking dirty east river water and purifying it, making it safe for swimming.

The Pool team still needs funding to make it a reality. Specifically, they need to raise $25,000 to begin physical tests of the filtration materials and methods by July 15th. With even more funding they can test and develop even more, and they expect it’ll take $500,000 to build a full-scale mockup of one of the parts of the swimming pool. As with any Kickstarter donation, the team will reward you with various goodies based on the size of your gift. More donations mean the faster this concept has a chance of becoming a reality.

 

Source:

 

Namaste Island

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namaste-island-1Just looking at this island one can’t help but be filled with a sense of calm and relaxation. The aptly named Namaste Island is located on lake Michigan near Traverse City. The stunning 7.5 acre island is adorned with a newly renovated cabin boasting a gourmet kitchen with high end appliances and beautiful deck offering panoramic views of the island scenery.

There is limited parking available on the shore lot and a public launch for your own private boat is visible from the island. The island is located almost within the Traverse City limits and it does have a Traverse City address, although it is close to the Interlochen School of Arts where many big name concerts are held throughout the year.

The island is heavily wooded and provides wonderful paths for walking. The sunrises and sunsets are magnificent and the moonlight and stars reflecting on the lake, which can be seen from your bed, defy description. And…in July there are wild blueberries for picking.

 

The island is currently on the market for $885,000 for more information on this property visit Private Islands Online.

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Shanghaied Away

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Hear the word ‘Shanghaied’ and thoughts of pirates, unsavory ship masters and blood money usually come to mind. Not so for Christina Gregor Hoheisel and her husband, Alex. Instead, they ‘kidnap’ each other for surprise trips to places unknown. Well, one of them always knows where they are going but they do take turns. Those types of surprises definitely makes life fun!

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New Rules On Medical Residents’ Hours Spur Debate – NPR

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Kaiser Health News
New Rules On Medical Residents' Hours Spur Debate
NPR
One year out of medical school, the tall 26-year-old internal-medicine resident often works up to 30 hours at a time. He sees it as a necessary part of his training. "You're definitely going to be tired," Oweis acknowledges, but with coffee and ...
Limiting resident physicians' work hours to save livesLos Angeles Times
New rules limit hours for first-year medical residentsScope (blog)

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RIVERSIDE: Med school dean says state funding key – Press-Enterprise

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abc7.com
RIVERSIDE: Med school dean says state funding key
Press-Enterprise
The dean of UC Riverside's proposed medical school said Thursday that five additional issues cited with the school's accreditation weren't as insurmountable as the inability to secure ongoing state funding that derailed the school's 2012 ...
UCR Med School requests $12 million grantThe Desert Sun
REGION: Lack of state support delays medical schoolNorth County Times
Calif. budget stalls opening of IE med schoolabc7.com
Inland Empire News -UC Riverside
all 12 news articles »

Three Professors Face Sanctions Following Harvard Medical School Inquiry – Harvard Crimson

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Boston Globe
Three Professors Face Sanctions Following Harvard Medical School Inquiry
Harvard Crimson
Three Harvard psychiatrists previously accused by a senator of accepting money from drug companies have been punished for violating conflict of interest polices set forth by the Harvard Medical School and Massachusetts ...
Harvard doctors punished over payBoston Globe
Harvard Punishes 3 Psychiatrists Over Undisclosed Industry PayVermont Public Radio
Doctors sanctioned for drug industry tiesUPI.com
San Francisco Chronicle -Bloomberg -Bizjournals.com
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SOS DD

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What does it take to become a doctor?  Endurance and perseverance help. It is a long haul from college to practice.  But the skill that is most beneficial is the ability to consume prodigious amounts of information, remember it, and recall it as needed.  Although I often relied on ‘B’ to get me through some of the exams.

Thinking, specifically critical thinking, is not high on the list of abilities that are needed to become or be a doctor. Day to day, doctors need to think clinically, not critically.  Clinical thinking consists of synthesizing the history, the physical and the diagnostic studies and deciding upon a diagnosis and a treatment plan.  It is not as simple as you might think.  When medical students start their clinical rotations and you read their notes, you realize they have what amounts to an advanced degree at Google U.  They know a huge amount of information, but have no idea how the information interrelates and how to  apply the that information to a specific clinical scenario.  With time and experience, and it takes at least a decade, students become clinicians and master how think clinically, but rarely the need to think critically.

The volume of data combined with time constraints ensures that we need to rely on the medical hierarchy to help manage the information overload required to apply science and evidence based therapy.  There is just to much data for one tiny brain to consume. Other doctors rely on me for the diagnosis and treatment of odd infections.  In turn, I  rely on the published knowledge and experience of my colleagues who have devoted a career to one aspect of infectious diseases.  There is little time for most doctors to read all the medical literature carefully, and usually little need.  We have people and institutions  we use as surrogates.

Not only is critical thinking usually not required to be a good physician, but medical practice can conspire to give physicians a false sense of their own abilities.  Really.  Some doctors have an inflated sense of self worth.  Who would have thought it?  Spend time with some doctors and listen to them pontificate on politics or economics with the same (false) assurance that have in their true field of expertise, and you will run screaming from the room.

Medicine is rife with confirmation error. In practice there is rarely negative feedback for making a wrong diagnosis, since everyone is wrong all the time. The good doctors are nimble, changing course quickly rather than sticking to a wrong diagnosis.  And there is no lack of positive feedback from good results.  There is the potential for unbalanced positive feedback to engorge the susceptible ego.  Last week I was walking downtown and was stopped by a lady, daughter of a patient, who introduced me to her friends as “the doctor who saved my mothers life.”  Not really true given that medicine is a team effort, and while I made the diagnosis others had missed, I know if it I had not made the diagnosis, some other ID doctor would have.  Talk about a chance for egoboo.  On the other hand, I must admit to great irritation when the hard work of the ICU team pulls someones bacon out of the fire and the credit goes to god.  I want to yell it was not god that saved your father, it was the doctors and nurses and respiratory therapists and the rest of the hard working, highly experienced ICU staff.  And just why did god make him so ill in the first place?   I do want at least partial credit and remain grateful that mind reading is not a reality.

The other weird thing that happens in medicine is the explicit knowledge we learn in medical school and residency over time becomes implicit.  I have discussed before how sometimes I can come to the correct diagnosis with  minimal information, almost intuition, and then explain after the fact how I came to the diagnosis.  It almost feels like the answer bubbles up from below awareness.   It is most peculiar how much of my medical reasoning occurs below my consciousness.  If  one is not careful that seeming quasi-omniscience could lead to a certain arrogance about your own abilities.  And if part of your job is to hold peoples living hearts in your hand?  It amazes me that the heart surgeons I work with are such nice, self-effacing people.

Add the lack of training in critical thinking to the weird combination of the Peter Principle and Dunning-Kruger Effect and you have a SCAM proponent in the making.  The first says that people rise to their level of incompetence, and if someone masters an area of expertise, they become incompetent in another field.  The latter suggests that “people make poor decisions and reach erroneous conclusions, but their incompetence denies them the metacognitive ability to appreciate their mistakes.”  When good docs go SCAM.

Starting with the basic sciences as a premed and working your way through the Brobdingnagian quantities of information to understand the workings of the human body in health and disease results in knowledge, but not necessarily wisdom;  learning not how to think, but what to think.  You have to trust that those up and down the line of experience know, at least in part, what they are doing: intern to resident to chief resident to attending to subspecialist.  I variously use team sport and hive intelligence to describe the practice of hospital medicine, although the Borg may be a better metaphor.  That being said, there is, at least in my small neck of the woods, little dogmatism.  Skeptics, die hard and otherwise, are often portrayed as close-minded and dogmatic, but in the teaching hospitals I practice in, explanations of the medical  literature are often filled with qualifications and caveats as we teach the residents.  How much of the great grey uncertainty that is medicine is passed on to patients is always an interesting question, and different clinicians will react differently to that clinical challenge.

I rarely see the caveats and uncertainty in the SCAM world that is common in medicine.  Often my answer to a consult is that the patient does not have an infection, or if they do, I have no specific therapy and you have to let the disease run its course. I wonder, in passing, if anyone has ever gone to a SCAM provider and been told: Nope. Sorry. Can’t help you. —Insert magic here— has no benefit for —insert disease here—. I bet almost never.

Patients use SCAMs for a variety of reasons, and I do not pretend to understand why people prefer magic over reality.  And, sounding like the arrogant tool of the medical industrial complex that I am, I wonder if part of the reason is they don’t know any better, and, really, most people have no reason to.  The average person has little motive or inclination to become immersed in the background required to understand why SCAMs are nonsense.  They have better things to do.

But MD’s?  You would think a doctor would know better. Astronomers do not flock to astrology.  Physicist do not push perpetual motion machines in large numbers.  Geologists do not become young Earth creationists in droves. It flabbers my gaster that, after learning all the information required to put MD after your name, anyone could find any validity in any SCAM.  Yet many do, too many.  Part of my assumption is that the Oz’s and Chopra’s and Weil’s of the world do not process information about the world in the same way the Gorski’s and Novella’s and Atwood’s do.  Either they never learned, or cannot learn, critical thinking, or, most importantly, applying the concepts to themselves.

I was originally dragging my feet writing this essay, as the topic was going to be Dr. Oz, who consistently demonstrates all the cognitive flaws and biases mentioned above.  The first thing I did when I received my medical school acceptance letter, besides checking the name to make sure it was really addressed to me and not a mistake,  was sell my electric typewriter, thinking I would never have to type again.  The thought of transcribing his shows filled me with dread, as my typing skills are barely up to the task to transcribing the thoughts in my head, much less the words that flow from Dr. Oz.  Imagine my delight when I came across an editorial in JAMA, Medicine’s Great Divide—The View from the Alternative Side,  by Dr. Chopra, which has the same odd world view and odd thinking with none of the transcription issues.  Cut and paste is so much easier.

The world of Dr. Chopra is radically different from the world in which I live and practice medicine.   My professional world view is equal parts an understanding of objective science and an understanding of the almost too numerous to count human intellectual and physical frailties and short comings that make applying science to patient care difficult and prone to error.  And that doesn’t even include just how hard it is to figure out what is going on in patients.  Of course, people never see themselves as other see them.  When I read Chopra’s account, I also have to ask myself, is my professional world view correct.  Or am I just this guy, you know?  But my Beeblebrox-like internal monologue reassuringly responds no.  Let us go todash.

Conventional medicine is offended that alternative medicine even exists. For the average physician, to hear that an allergy patient is taking extract of nettle to treat his symptoms or that a breast cancer patient is being treated with coffee enemas and a macrobiotic diet arouses scorn. Over a decade ago, when the New England Journal of Medicine reported that Americans pay more visits annually to alternative practitioners than to MDs, the attitude of the editorial writer was barely disguised dismay and disbelief. It was as if the whole country had turned its back on jet travel to return to the horse and buggy.

I do not speak for conventional medicine,  or as I like to call it, medicine, only for myself, but I do have a sense of dismay when  doctors use and promote SCAMs.  Other people?  Not so much.  Dr. Chopra evidently feels that relying on the irrational magics of earlier ages to be a reasonable way to approach health and disease.  It is  worse than horse and buggy, which will at least get you to your destination.  SCAMs are the intellectual equivalent of returning to demon exorcism, cupping, bleeding  and purging to treat and prevent illness. It is applying the principles of Harry Potter in a world where disease and death are real.  In my world view, a bad idea.  On the other hand, in the entire essay, he never once mentions a specific wackaloon SCAM as worthy for use in patient care, preferring to focus on the shortcomings of medicine.

Yet at bottom no one could really object to the aims of alternative medicine, which are to bring relief to the whole patient.

What is that old road to hell paved with? I can’t recall.  Object to the aims? No. Everyone thinks they are acting in a beneficent manner  he writes resisting the urge to be accused of Godwins Law.  The methods?  Well, yeah, I object to the methods,  The objections with SCAMs have nothing to do with aims, Dr. Strawman.  It is with how those aims are accomplished.  I have trouble trusting peoples health and well being with interventions that have no basis in my understanding of reality.

He spends the rest of the paragraph dwelling on the pathologies of  modern medicine: the lack of time and the unpleasant environments of modern hospitals, with the usual implied argument that since medicine has issues, SCAMs must be valid and the solution.

In other words, the other party in the divorce—those who have lost faith in conventional medicine—has its own valid reasons.

Because I am fat,  therefore  you are  thin.  It gets tiresome seeing the same flawed arguments.  Has Dr. Chopra never bothered to peruse the cognitive error or logical fallacies pages on the Wikipedia to at least casually educate himself on the bare minimum of critical thinking?  SCAMs of all stripe have to have to stand or fall on their own merits, not on the perceived and real failings of medicine.  The response of my hospitals to the problems with medicine has not been to abandon medical science in favor of nonsense, but to rigorously apply the results improve on what we have, with remarkable results.  We have made the airplane fly better, safer and more comfortably, not abandoned the airplane in favor of levitation.  Italics mine:

The two camps are not as opposed as they once were. Twenty-five years ago the possible efficacy of traditional healing modalities, herbs, Eastern therapies like acupuncture, and even mind-body medicine was so foreign as to be entirely alien. Today there are still die-hard skeptics (ie people with a consistent understanding of reality who understand that the shortcomings of human cognition apply to themselves as much as to others), of course. But in a mood of expanded tolerance (read easy money), an MD can look at the research on neurotransmitters, cell membrane receptors, and brain physiology, which has made enormous strides in recent decades. Taken as a whole, this research describes the body as an integrated system that exchanges information continuously between the mind, via the brain, and every cell in the body.

What? Huh? Say what?  I can’t see how the first part of the paragraph relates to the second half of the paragraph.  I have to admit, with a child in middle-school, I have been reading my sons five-paragraph essays, with their emphasis on logical flow and coherence, so perhaps I am out of practice with reading essays written by adults and miss the subtle connections between alien modalities and modern neurophysiology.

One aspect of SCAM proponents I note is they like to take obvious conclusions, what should be almost banal statements, and make them seem like they are profound insights into the human condition available only to SCAM proponents, “the body as an integrated system that exchanges information continuously between the mind, via the brain, and every cell in the body.”  Well, duh.

I guess Dr. Chopra hasn’t spent time on rounds in the hospital for a while, where the endless permutations of physiologic interactions and complexity are discussed, observed and modified.  Understanding these interactions is part of what makes the practice of medicine, real medicine,  so damn hard.  It must be so much easier to do some quantum mind-body hand waving and not have to actually fret about the application of practical physiology.

With real-time scans from functional MRIs staring them in the face, MD’s have no reason to look upon the placebo effect, for example, as “not real medicine.” When patients feel relief from chronic pain by being given a sugar pill, the body’s endorphins are filling the same receptor sites in the brain that externally administered opiates fill.

Placebo has always been real medicine, the question is whether using a placebo is ethical (it is not, since lying to a patient is not ethical) and how effective placebo is (for pain, barely efficacious, for any other disease placebo has no effect).  In my world view placebo is wrong, because lying to patients is wrong, its effects are marginal (especially for infections) and I have yet to find a way to use placebo without lying to a patient.

But SCAM practitioners have a key insight that only they have access to: the importance of diet.  Of course he transitions into the old trope that diet is alternative. Alternative to starving I suppose.  As my son would say to me, how edgy. Changing diet can improve cardiovascular disease. <sarcasm>WTF. No one ever told my ever in the last 25 years that diet was important for cardiovascular and other diseases. I want a refund from OHSU.</sarcasm>.  It is important for SCAM practitioners to pretend that diet is somehow alternative, and then by extension, validating real nonsense in fields like reiki or acupuncture or homeopathy.  SOS DD.

Seriously, what offends me is not alternative medicine, but sloppy, inaccurate, lazy thinking, be it in SCAMs, politics or literary criticism.  And so much of SCAM is sloppy thinking, sometimes from educated people who I think should know better.  But I remain of the opinion that sloppy thinkers make sloppy doctors.  Dr. Chopra is a board-certified endocrinologist, and he is trying to imply with a straight face that lifestyle changes, diet and exercise, are not at the core of the approach to type 2 diabetes and cardiovascular disease?  Ground rounds this week was an update on hypertension.  The first part of the lecture?  Diet and exercise.  It is the old truth that if you repeat a lie often enough, people will come to think it true.

One sign of growing reconciliation comes in the form of softened terminology. Instead of calling it alternative or holistic medicine, as I’ve been doing, the more acceptable term is complementary and alternative medicine (CAM), which sends the signal, “See? I am not your foe. We can cooperate. We’re complementary.” Which is true.

It reads like Jake Chambers final essay. You have to watch CAM all the time, CAM is a pain and that is the truth. Really? You can add nothing to something and increase its value?  If the integrative medical centers ever go under, they may have a job on Wall Street. 1 plus 0 is not 2, except in the world of SCAM.  See.  I am your foe.  You offer nothing of value.  Which is true.

Then he shifts to reality mixed with BS. Italics mine:

The problem is that an MD’s practice is badly set up to promote prevention (often true). Visits are too short (yep).  Aren’t adequately trained beyond their specializations (BS). Their habits are focused almost entirely on drugs and surgery as treatment modalities (BS). Prevention is considered too “soft,” (BS) and yet, if you shift the burden of prevention to the patient (lets call it empowerment when the SCAMsters do it) (which most MDs are more than happy to do (lets call it a partnership when the SCAMsters do it)), there is enormous resistance (BS). The public has been given countless warnings about smoking, poor diet, and lack of exercise, yet we have by no means eradicated lung cancer, obesity, coronary artery disease, and type II diabetes (true). Lifestyle disorders prove intractable when people cling to bad lifestyle habits and resist adopting good ones (true, but whose ‘fault’ is that?). We remain a nation of sedentary overeaters, paying pious lip service to prevention while doing less than enough about it (true, but is the solution in SCAM?).
This is where CAM makes significant inroads, because one of its main themes is the return of power to the patient.

See, I told you where this was going.  Doctors dump, CAM returns power to the patient.  I love the language of BS.  The lessons of Animal Farm and 1984 remain relevant in 2011, and probably for the life of the human species.  I imagine that those who seek SCAMs are motivated to see a benefit from a particular SCAM.  SCAM providers see a self-selected population who want to have results from what ever modality they are using.  I would wonder how effective any SCAM based therapy would work if tested on a population of CFI or JREF members. So much potential for confirmation bias in the assertion that SCAMs have a unique ability to alter peoples behavior by empowering the patient.

MDs should welcome the whole trend to self-treatment instead of taking the scornful attitude that nothing works but the modalities taught in medical school.

So when is shifting the burden magically transformed into a trend to self treatment? When it is offered by a SCAM practitioner. Most MDs are aware that medical school is the beginning, not the end, of learning, and also recognize that it is as important to know what isn’t effective is as important as knowing what is effective.  It is why medicine evolves and SCAMS are intellectually stagnant.  Dr. Chopra seems to invent a world that does not exist, at least in Portland, and then rail against it. Trying to engage the patient is their care  has been a goal in medicine for decades.

The real mystery—one that deeply intrigued me 25 years ago—is that so many therapies that totally disagree with one another manage to bring results. Ayurveda isn’t qigong; yoga isn’t Reiki; none of them is a placebo. Yet somehow healing exists, and the channel it takes can be quite unexpected and inexplicable.

The real mystery is that so many forms of astrology totally disagree with another manage to bring results.  No mystery if you live in a reality-based environment.  The real answer, the rational answer, is that none of them do diddley.  People often get better and always have and the ability for people to fool themselves and others is endless.  That paragraph, more than any other in the essay,  sums up the difference I see between SCAM proponents and SBM: a complete lack of insight and critical thinking that allows people to not recognize their own limitations in understanding the world.  Yet I am the closed minded arrogant tool. Sheesh.

Continuing in a vein separate from the world I work in,

The inconvenient truth that “you can heal yourself” has always been the foundation of medicine. The body is the locus of the healing system; physicians assist this complex, little-understood system. They do not actually do the healing. If this feels threatening to MDs, there is much more room for pride to take a fall.

Dude, its not inconvenient at all. We all know that.  No one is threatened.  So many Stuffy Guys, I worry about a tremendous conflagration should nonsense arguements become flammable.  What’s next?  We in SCAM understand that water is wet and fire is hot?  Only SCAM practitioners seem to make it a virtue to trumpet the obvious as if it were some profound truth. Little understood?  What, you give up reading the literature? Understanding of healing is not complete, but it is broad and deep.

Conventional medicine also faces the mysterious “decline effect”—established medications steadily lose their effectiveness over time, as if the newer generation of patients has different, less receptive physiologies.

Is this willful ignorance?  Massive confirmation bias?  Mysterious? Really?  Doesn’t he read and think about these topics? Dr. Steven Novella:

…it is no surprise that effect science in preliminary studies tend to be positive. This can be explained on the basis of experimenter bias — scientists want to find positive results, and initial experiments are often flawed or less than rigorous. It takes time to figure out how to rigorously study a question, and so early studies will tend not to control for all the necessary variables. There is further publication bias in which positive studies tend to be published more than negative studies.
Further, some preliminary research may be based upon chance observations — a false pattern based upon a quirky cluster of events. If these initial observations are used in the preliminary studies, then the statistical fluke will be carried forward. Later studies are then likely to exhibit a regression to the mean, or a return to more statistically likely results (which is exactly why you shouldn’t use initial data when replicating a result, but should use entirely fresh data – a mistake for which astrologers are infamous).

Are SCAMs immune from the decline effect?  Probably, since you can’t decline past zero. Any further decline in the effects of homeopathy or acupuncture or energy therapy would soon cross into increasing the symptoms they are attempting to  treat.

For me, the most distressing aspect of the decline effect is how widely it is being ignored.

Come on rounds, Dr. Chopra.  Listen to our Intensivists discuss the use of steroids in sepsis or the Cardiologist discuss the approach to acute coronary events with the residents.  The history of the literature, why the approach has evolved as the studies have refined and extended our understanding.  The decline effect is an integral part of the teaching of medicine, it is an integral part of the history of science and the evolution medicine.  Just like the complexity and the integrated systems of the body, it is part of the foundation of the practice of medicine, although, like much of the foundations of medicine, rarely explicitly stated, except as a source of pseudo-profundity.

More distressing appears to be the inability to apply the same worry to SCAMs, where the history demonstrated increasingly better studies of SCAMs resulting in decreasing efficacy until well designed, bias free studies show no efficacy. Not a decline effect, but a crash, burn and explode effect, always ignored by the SCAM proponents.  Oh well, a foolish inconsistency is adored by SCAM minds and its philosophizers.  If you think medicine has issues, read the CAM literature.  It is nice how artfully Dr Chopra fails to note that the literature in the SCAM world is several logs worse and almost no intervention has any physical or biological plausibility.

My purpose isn’t to justify the vast universe of healing modalities that exist outside Harvard Medical School (Besides the Palin-esque stab at populist anti-intellectualism, I note that Harvard is long past it’s prime as a medical arbitrator, what with the Osher Clinical Center and all.  Harvard has consumed the Kool-aid). I look instead toward the next phase of this reverse marriage, which is shy courtship. If both sides stopped being defensive, they would see that they share core values: treating the whole patient, reducing suffering, closing the gap between healer and healed, and doing the least harm while bringing the greatest good.

Whoops. Forgot a core value: trusting patients lives and fortunes to therapies that have efficacy based on reality and that are effective. Small thing, I know, but I am old school and feel obligated to treat patients with therapies that are effective beyond the self delusions and biases of the practitioner.

With that in mind, I have little desire to debate with skeptics and scientists who disdain CAM and falsely claim that only their side is valid and evidence-based. The mystery of healing remains unsolved.

Whew. I guess he will not be responding in the comments and prefers to live in his own world.  Like people who only watch Fox news.  This week I helped cure/heal two heart valve infections, a relapsing fever, a malaria and a handful of pneumonias and skin infections.  No mystery there for me.  Do I understand all parts of healing?  Nope.  Does that invalidate the parts I do understand? Nope. Would any SCAM have ‘complemented’ any part of my patients course?  Nope.  I do agree that SCAMs are evidence-based, it is just that the science and evidence demonstrates they do nothing and that science and evidence has validated their worthlessness.

He concludes

The next step will be to remodel medical school curricula so that future physicians are not wandering in the dark as my generation did, totally ignorant, if not blind, about treatments outside our narrow band of knowledge. Expanded medicine is the answer, I am sure of that.

Just as I am sure the world will not be improved by SCAMs modalities.  For fun, let us make a list on the advances in human health made in the last 100 years, in the US or elsewhere, due to application of any SCAM:

 

 

 

 

 

 

 

 

 

 

 

My wife likes to say if you want to predict the future, look at the past.

I do not practice in the world of Dr. Chopra or understand its allure.   His medical world is divorced from the one I work in, and his approach to understanding medicine could be used as a textbook examples on logical fallacies,  cognitive errors, and disingenuous argument.  I am less than impressed. As Dr. Feynman said, “The first principle is that you must not fool yourself, and you are the easiest person to fool.”  Unless you think the future is expanded medicine.

SOS DD: same old stuff, different Doc.  It has other meanings.

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Update on Josephine Briggs and the NCCAM

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Dr. Gorski is in the throes of grant-writing, so I’m filling in for him today by following up on a topic introduced a few months ago. It involves a key medical player in the U.S. government: Dr. Josephine Briggs, Director of the National Center for Complementary and Alternative Medicine (NCCAM).

Background

Steve Novella and I first encountered Dr. Briggs at the 2nd Yale Research Symposium on Complementary and Integrative Medicine in March, 2010. I reported here that she seemed well-meaning and pro-science but that she also seemed naive to the political realities of her office and to much of the content of “CAM” (as illustrated by her recommending the NCCAM website, which is full of misinformation; previously I’d noticed her unfortunate innocence of “acupuncture anesthesia,” which is to be expected of most academics but not of the CAM Explicator-in-Chief).

Shortly thereafter, Drs. Novella, Gorski, and I visited Dr. Briggs at the NCCAM, after (to our surprise) she had requested our presence. Dr. Novella reported on that visit here, noting that Dr. Briggs’s call for science to be neutral “could easily fall into the trap of false balance (balancing legitimate scientific evidence and analysis with pseudoscientific promotion).” She also refused to discuss the rotten-to-the-core Trial To Assess Chelation Therapy (TACT), instead passing the buck to the NHLBI, which also apparently will not discuss it. I wonder why?

Nevertheless, there were suggestions at that meeting that Dr. Briggs might use her position to do some good. We explained several examples of misinformation in the NCCAM newsletter that we’d found in the waiting room; she seemed to agree with at least some of our points. She portrayed an appropriate skepticism about homeopathy. She agreed that “CAM” advocates are especially likely to be opposed to vaccinations, and that the NCCAM ought to address this on its website. She insisted, when asked (again), that the NCCAM now looks favorably upon proposals for legitimate natural products research—which, if true, marks a distinct shift from its previous bias toward zealous herbalism.

Report Card

So how’s Dr. Briggs been doing since then? Mostly not so well. Almost immediately after Steve’s report hit the screen, we discovered that a few weeks before our meeting she’d met with an “international team of homeopaths” who left the building feeling quite satisfied that they had made a favorable impression on Briggs and her colleagues. Her own account of both meetings revealed exactly the “false balance” that Dr. Novella had warned about.

A few months later Dr. Briggs made the regrettable decision to lend her imprimatur, along with those of the NIH and the federal government, to the formal celebration of quackery titled the “25th Anniversary Convention of the American Association of Naturopathic Physicians” (AANP). In an open letter posted on SBM I attempted to explain why this was a bad idea. Dr. Gorski also expressed his dismay. So did Dr. Benway. Dr. Briggs seems to have noticed our displeasure: according to a trusted source who viewed the eventual conference videos, she began her talk to the naturopaths by remarking that some people had made the curious claim that her very presence (as a “keynote speaker”) at the conference would imply her endorsement of the proceedings. Jeez: some people can really jump to conclusions, eh?

Well, a few months later Dr. Briggs nominated Jane Guiltinan, ND, Past-President of the AANP and Dean of Naturopathic Medicine for Bastyr University, to be the newest member of the National Advisory Council for Complementary and Alternative Medicine (NACCAM). Here is the nominee’s Philosophy:

Dr. Guiltinan emphasizes the concepts of treating the cause of a problem, supporting the body’s own healing process and encouraging patients to create their own wellness even in the face of serious illness. Dr. Guiltinan uses nutrition, plant medicine and homeopathy in her practice and believes that air, water, food, touch, love and laughter are some of the most powerful healing agents.

Not to put too fine a point on it, but with that repertoire of ‘healing agents’ patients will have no choice but to create their own wellness in the face of serious illness. Dr. Briggs, of course, has no choice but to nominate such people to the NACCAM, because such is required by (Sen. Tom Harkin’s) law. Jane Guiltinan, all things considered, is probably about as benign a nominee as one could hope to find among the universe of magical thinkers from which Dr. Briggs must make her selections. Then again, Dr. Briggs needn’t choose to remain Director of a bogus NIH Center.

In November, for Vaccine Awareness Week, I decided to find out whether Dr. Briggs had yet posted any useful discussions of immunizations and antivax fanaticism. I could find none, but I found plenty of the usual misinformation.

Since then, however, Dr. Briggs has finally posted such an article. She begins by dangling some questionable and irrelevant bait:

People turn to complementary and alternative medicine (CAM) seeking better health. Several studies have found an association between use of CAM and positive health behaviors such as getting regular exercise, not using tobacco products, and following a healthy diet. CAM use also has been associated with higher rates of vaccination for influenza, pneumococcus, and hepatitis B among adults.

Then she squints and tiptoes onto the battlefield:

Unfortunately, however, this may not be the case for vaccinations in children.

No! Really?

A recently reported NCCAM-funded study in the Maternal and Child Health Journal showed that children in Washington State who received care from CAM providers were substantially less likely to get recommended immunizations and were more likely to be diagnosed with a vaccine-preventable disease.

What?? Why didn’t anyone tell us this before? Don’t worry, though, it ain’t necessarily the poor “CAM providers”—our stakeholders, doncha know—who are at fault here:

The investigators note that their findings do not provide an explanation for the association.

All right, it’s time to stop being so flippant, even though anyone with a passing knowledge of sCAMmery knows that it’s both the sCAM artists and their willing marks who collaborate in science-based medicine denial, that there have been countless articles for a couple of decades demonstrating the culpability of the “providers” themselves, and that most of those articles were written without the benefit of NCCAM funding. Here, for example. Hmmm…Washington state: home of the largest population of NDs in the country, and of Bastyr U. (ahem)

But enough. Other than the objections just made, Dr. Briggs’s statement on childhood vaccinations is a pretty good one, and it links to an even better entry, also new in April, 2011, titled NCCAM Clinical Digest: Childhood Vaccinations/Immunizations.

Goodonya, Josie, but I still think you oughtta tell Tom Harkin to take that job and shove it. It doesn’t become you.

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Magnets and Blood Flow

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Over the last week I have received numerous questions about a recent study (yet to be published, but highly publicized in the press) in which it is claimed that the application of a magnetic field can improve blood flow. Physics World declared in the headline that, “Magnetic fields reduce blood viscosity.” This is not a bad summary of the study, but then the first sentence claims:

Researchers in the US claim that exposing a person to a magnetic field could reduce their risk of a heart attack by streamlining the flow of blood around their body.

Science Magazine ran with the also tame headline of “Magnets Keep Blood Flowing” but also had some problems in the text of their report (which I will get to).

The amount of press attention the study is getting is a bit odd. It’s a small proof-of-concept study looking at the effects of strong magnetic fields on blood flow in vitro. I suspect part of the reason is the same as why so many people have been asking me about it – magnets are frequently marketed with health claims and these claims are often justified by the hand-waving explanation that magnetic fields improve blood flow. The concern is that this small study will be abused by huxsters to sell refrigerator magnets with unfounded health claims.

The history of health claims for magnets goes back as far as knowledge of magnetism itself. In the last decade there appears to have been an upsurge in this old scam – a plethora of products promising to treat arthritis, improve healing, or just give extra energy by placing a magnet over the target area. The magnets used are typically very weak and have a field that barely penetrates the skin, let alone reaching down to the joints or the area of pain.

Further – these products are generally using static magnets. Static magnetic fields would not be expected to have any effect on nerve function or blood flow. It is not surprising, therefore, that the clinical evidence for any efficacy is also negative.

This study is very different, and therefore has no applicability to any magnet product on the market (if it has any applicability at all). Physicists Rongjia Tao Ke Huang took donated blood and then measured its viscosity in a small tube used for that purpose. They then applied a 1.3 Tesla magnetic field to the tube (this is about the strength of the magnetic field used in a typical MRI scanner), with the field aligned with the direction of blood flow, for one minute and found that the viscosity decreased by 20-30%. This effect lasted for about 2 hours.

There are numerous problems with extrapolating from this study to a net clinical effect, and also in the interpretation of the mechanism of the effect. The researchers claim that the effect comes from the red blood cells clumping together, mostly in a line, like box cars on a train. The cells moving together as a train produces less resistance than if they were all bouncing around separately. Further, they tend to flow more down the middle of the tube, reducing friction with the tube wall.

The picture above shows the clumping of the cells. Immediately it seems as if there can be a problem applying this to a person. The glass tube used in the study was larger than the smallest arteries in people. Further, capillaries are only large enough to allow red cells to flow through single file. I would not want my red cells clumping as in the picture above and then trying to squeeze through capillaries. I would not be surprised if the effect on viscosity were reversed for smaller arteries, or even caused serious problems with capillary flow. But I suspect the net effect on blood flow in vivo is negligible, because we have been exposing people to magnetic fields of this strength in MRI scans for a couple decades now without any ill effects.

Another major problem is that the effect only happened when the field was aligned with the (straight) tube. Arteries in a living organism are not straight and are not parallel. They will be traveling every which way in relation to an external field. This will probably be the greatest limiting factor in applying this effect to organisms.

The effect (even in the optimal and contrived conditions of the study) was also short-lived – only two hours. Even if the effect could be achieved in a person, this makes it impractical for any application of routine prevention – such as preventing heart attacks and strokes as was reported in most articles on the study. I could imagine an application to an acute event, such as during a heart attack or stroke, and focused on a single blocked artery that can be aligned with the field. But even then, for the reasons stated above, I doubt the net clinical effect will be significant or necessarily positive.

Regarding mechanism, the Science Magazine article reports:

The magnetic effect, the researchers say, all comes down to hemoglobin, the iron-based protein inside red blood cells. In the same way that iron filings align themselves along the field lines around a bar magnet, so the red blood cells align themselves along the straight field lines of Tao and Huang’s electromagnet.

There is a significant problem with the  analogy of hemoglobin to iron filings – iron is ferromagnetic, which means it has a strong response to an external magnetic field (in addition to the ability to retain a magnetic field itself, but this is not as relevant to the current study). The iron in hemoglobin is not ferromagnetic. Ferrohemoglobin (without oxygen attached) is weakly paramagnetic (is attracted to an external magnetic field). So it can align with a strong external magnetic field, but this effect is generally very weak. Oxyhemoglobin is non-magnetic (has a magnetic moment of zero, because it has no free electrons) and therefore does not respond at all to an external magnetic field. So oxygenated blood in arteries would have a very weak to no response to to an external magnetic field due to its hemoglobin.

Red cells themselves may be weakly diamagnetic – meaning they are repulsed by an external magnetic field (this is why a frog levitates over a powerful magnetic field) and this may be the effect that causes the observed clumping.

To reinforce this point, the weak paramagnetic or diamagnetic properties of cells or living tissue require a strong magnetic field to have any effect – like an MRI magnet. The small relatively weak magnets used in products with health claims are orders of magnitude too weak to have any such effect. The hemoglobin gambit (based on the fact that hemoglobin contains an iron atom) collapses under close examination.

Conclusion

It is interesting that a strong magnetic field can have a temporary effect on red blood cells. Whether or not this effect will have any future clinical applications remains to be seen. I doubt it, for all the reasons I explained above, but it’s possible someone may find a clever use for this effect.

The simplistic extrapolation from this contrived and temporary effect to improving blood flow and thereby reducing risk of heart attacks, however, is unjustified and misleading. Further, any attempt to use this study as a justification for clinical claims made for weak permanent magnets is beyond misleading , in the realm of the absurd.

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Virtual Colonoscopy Can Be Hazardous to Your Health

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The US Preventive Services Task Force (USPSTF) recommends that everyone aged 50-75 be screened for colon cancer with any one of three options: colonoscopy every 10 years, flexible sigmoidoscopy every 5 years, or fecal occult blood testing (FOBT) every year. Conventional colonoscopy is considered the “gold standard” since it allows for direct detection and biopsy of early cancers and removal of precancerous polyps. It involves passing a long colonoscope via the rectum through the full length of the colon and is also known as optical or visual colonoscopy. A newer and less invasive alternative, virtual colonoscopy or CT colonography, is being promoted by some as the test of choice. Others disagree. One area of controversy is that CTs frequently find “incidentalomas” that require further investigation. An article in the journal Radiology highlights this problem, describing “the clinical drama that follows screening or diagnostic tests.”

Virtual colonoscopy, or CT colonography, has some advantages:

  • No sedation required.
  • Avoids the discomfort and the small risk of bowel perforation that accompany colonoscope insertion.
  • Takes less time.
  • Visualizes right colon (not well visualized in 10% of optical colonoscopies).
  • It is as effective as optical colonoscopy in finding advanced cancers, but results in far fewer polypectomies.
  • May identify abnormalities outside the colon.

It also has some disadvantages:

You will notice that identification of abnormalities outside the colon is listed as both an advantage and a disadvantage. Assessments of risk/benefit ratio differ. In a 2005 study of 500 patients published in Radiology, CT colonoscopy found “a substantial number” of clinically significant findings, including aneurysms and a renal carcinoma; but it did not establish whether finding them improved outcomes. 28% of the significant findings had already been diagnosed prior to colonoscopy; and the patient with the renal carcinoma declined treatment, since he already had metastatic colon cancer. In a 2009 study of 143 patients, 98% of patients had at least one incidental finding outside the colon. 24% of these required further evaluation, with 73 imaging studies, 30 lab studies, 44 clinical visits, 6 medical procedures, and 44 return visits over a mean period of 38 months. The cost was estimated at $248 per patient. They did not assess whether these evaluations improved eventual patient outcomes.

Writing in the journal Radiology, Dr. William Casarella, a radiologist at Emory University School of Medicine, tells the story of his own virtual colonoscopy. His colon was normal; but the CT also showed areas outside the colon, revealing a kidney lesion, a 2 cm. mass in the liver, and multiple non-calcified nodules in the bases of both lungs. These findings led to the following tests and interventions:

  • A contrast-enhanced CT of the abdomen (with more radiation) showed that the kidney lesion was a benign cyst, but the liver mass was not.
  • A high-resolution lung CT (more radiation) confirmed lung nodules.
  • A CT-guided (more radiation) liver biopsy (more risks) showed necrotic tissue, no definitive findings.
  • A PET scan (more radiation) was negative.
  • Video-aided thoracoscopy
  • 3 wedge resections of the right lung (requiring the lung to be collapsed), resulting in a diagnosis of histoplasmosis (benign, no treatment indicated).

The lung surgery led to:

  • 5 hours in the recovery room before awakening from general anesthesia.
  • Chest tube, subclavian central venous catheter, nasal oxygen catheter, epidural catheter, arterial catheter, subcutaneous heparin injections, prophylactic antibiotics, IV narcotics (each with associated risks).
  • Excruciating pain requiring narcotics for 2 weeks.
  • 4 weeks of disability.
  • Persistent chest pain due to surgical interruption of intercostal nerves.

The total cost was over $50,000.

This is an atypical example, but it underlines the potential dangers of too much information. Sometimes ignorance is bliss. Dr. Casarella would have been better off had he not been screened for colon cancer at all. I support the USPSTF recommendations, but it is important not to over-rate the value of these tests. The public perception is “get this test: it will save your life.” The reality is more complicated. Screening tests can have false positive and false negative results. They don’t always provide clear black and white answers, and they don’t save as many lives as the public tends to think. While statistically benefiting the population, they may be hazardous to the health of some individuals. We need to keep in mind that even the best screening tests have a downside.

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Utah Senator Orrin Hatch: A pit bull in defense of the supplement industry

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Editor’s note: This weekend was truly NIH grant crunch time. I have to get my final version of my R01 to our university’s grants office by Tuesday, or it might not get uploaded by the July 5 deadline. (Funny how electronic submission, which was supposed to make applicants’ lives easier, seems to have made them harder.) Consequently, I decided to take a few minutes and spiff up a post I did not long ago for my other blog and use it here, mainly because it is particularly relevant to our usual SBM topics. I’ll be back next time with something new.

The weakness and ineffectiveness of the law in the U.S. regulating dietary supplements has been a frequent topic here on Science-Based Medicine, including the continued failure of efforts to address the serious shortcomings of current law and the illogic at its very heart. Indeed, over the last decade or so that I’ve paid attention to relevant issues regarding supplements continually amazed at how much supplement manufacturers can get away with and for how long. For example, one of the most recent atrocities against science occurred when Boyd Haley, disgraced chemistry professor at the University of Kentucky and prominent member of the mercury militia wing of the anti-vaccine movement, tried to sell an industrial chelator as a dietary supplement to treat autistic children. True, that was too much even for the underfunded, undermanned FDA to ignore, but it was amazing how long he got away with it. Apparently it takes someone trying to market a chemical compound that can’t by any stretch of the imagination be characterized as a “nutrient” or “food” to be so obviously against even the travesty of a mockery of a sham of a law regulating supplements (the Dietary Supplement Health and Education Act of 1994, or the DSHEA) that the FDA could take action.

Of course, here at SBM, we’ve written numerous posts on the shortcomings of the DSHEA. Basically, this law created a new class of regulated entities known as dietary supplements and liberalized the sorts of information that supplement manufacturers could transmit to the public. The result has been this:

It [the DSHEA] also expanded the types of products that could be marketed as “supplements.” The most logical definition of “dietary supplement” would be something that supplies one or more essential nutrients missing from the diet. DSHEA went far beyond this to include vitamins; minerals; herbs or other botanicals; amino acids; other dietary substances to supplement the diet by increasing dietary intake; and any concentrate, metabolite, constituent, extract, or combination of any such ingredients. Although many such products (particularly herbs) are marketed for their alleged preventive or therapeutic effects, the 1994 law has made it difficult or impossible for the FDA to regulate them as drugs. Since its passage, even hormones, such as DHEA and melatonin, are being hawked as supplements.

One might wonder how such a bad law could survive for so long (seventeen years now), but it has its defenders. One man, in particular, defends the DSHEA against all regulatory threats, foreign and domestic. His name is Senator Orrin Hatch (R-UT), and he was just the subject of a writeup in the New York Times last week referring to him as a “natural ally” of the supplement industry:

A drive along mountain-lined Interstate 15 here shows why Senator Orrin G. Hatch is considered a hero in this region nicknamed the Silicon Valley of the nutritional supplement industry.

In the town of Lehi is the sprawling headquarters of Xango, where company officials praised Mr. Hatch, a Utah Republican, late last year for helping their exotic fruit juice business “operate without excessive intrusion” from Washington.

Up in Sandy, Utah, is 4 Life Research, whose top executives donated to Mr. Hatch’s last re-election campaign after federal regulators charged the company with making exaggerated claims about pills that it says helps the immune system.

And nearby in West Salem, assembly-line workers at Neways fill thousands of bottles a day for a product line that includes Youthinol, a steroid-based hormone that professional sports leagues pushed to ban until Mr. Hatch blocked them.

And, as the article goes on to mention, Hatch was the principal author of the DSHEA. Fast forward seventeen years, and these days any time the Obama Administration tries to write rules to regulate supplements more strictly, Orrin Hatch is there to do his damnedest to block them. Because Hatch is a very senior (and therefore powerful) Senator, he nearly always succeeds. Indeed, as the NYT article points out, the relationship between Hatch and Utah’s massive supplement industry been a hugely mutually beneficial one, and the article also describes just how incestuous it has been as well. First of all, there’s an enormous amount of campaign contributions that Hatch garners every election cycle from supplement manufacturers, but the relationship goes so much more deeply than that:

His [Hatch's] family and friends have benefited, too, from links to the supplement industry. His son Scott Hatch, is a longtime industry lobbyist in Washington, as are at least five of the senator’s former aides. Mr. Hatch’s grandson and son-in-law increase revenue at their chiropractic clinic near here by selling herbal and nutritional treatments, including $35 “thyroid dysfunction” injections and a weight-loss product, “Slim and Sassy Metabolic Blend.” And Mr. Hatch’s former law partner owns Pharmics, a small nutritional supplement company in Salt Lake City.

But many public health experts argue that in his advocacy, Mr. Hatch has hindered regulators from preventing dangerous products from being put on the market, including supplements that are illegally spiked with steroids or other unapproved drugs. They also say he is the person in Washington most responsible for the proliferation of products that make exaggerated claims about health benefits.

Many are the times that I’ve complained about a different Senator, namely Senator Tom Harkin (D-IA) for his advocacy of pseudoscience that led hm to foist the atrocity that is the National Center for Complementary and Alternative Medicine (NCCAM) upon an unsuspecting nation. However, as bad as Tom Harkin is, he is nonetheless also widely appreciated as a staunch advocate of the National Institutes of Health and other funding for legitimate medical research. This has been true for decades, and he has been honored as such more than once. The problem is that, along with all that advocacy for the NIH, Harkin has a very hard time distinguishing worthwhile medical research from quackery. Even so, arguably he has supported enough good medical research that his unwavering support of NCCAM can almost be forgiven. Almost. Hatch, on the other hand, has no such redeeming quality to counterbalance his support for quackery and his defense of supplement manufacturers against any government law or regulation, no matter how reasonable, that might jeopardize their profits. Not surprisingly, he denies that this is true in the NYT article. He even has the gall to claim that he’s been a champion of regulating supplements, a claim that is so risible that it’s hard to believe he could make it with a straight face. I guess that’s why he’s a politician.

I am gratified, though, that the NYT didn’t forget to point out that there’s a new Republican quackery supporter in town, and he’s out to unseat Hatch by–you guessed it–sucking up to the supplement industry even more than Hatch does. His name is Jason Chaffetz, and he’s a former supplement company executive turned U.S. Representative and co-chair of the Dietary Supplement Caucus. (Yes, there really is such a thing.) I wrote about him not too long ago because of his support for what I then termed the “wonderfully Orwellian” Free Speech About Science Act of 2011 (FSAS). Boiled down to its essence, the FSAS would weaken even more the already desperately weak DSHEA. Basically, under the auspices of allowing “more free speech about food,” it would neuter the FDA with respect to claims about supplements, and it would do it through a very clever turnabout regarding the use of peer-reviewed research in that it places the burden of proof on the FDA to demonstrate that scientific studies used to bolster health claims for food and supplements are not good research. One can see the obvious problem with that. Supplement manufacturers could claim anything they wanted, as long as they could pull out a scientific paper or two, and it would be up to the FDA to have to refute them. Like the case for quacks, it wouldn’t be too difficult for supplement manufacturers to produce a constant stream of dubious research to point to, allowing the to make almost any claims they want to with impunity.

Fortunately, that law appears not to be going anywhere right now, and I hope it doesn’t. However, it was only a year ago that Hatch demonstrated why he is the master when it comes to protecting his supplement industry backers. That was when John McCain tried to pass legislation to tighten the regulation of supplements, Orrin Hatch and the supplement industry slapped him down in no uncertain terms. Basically, McCain ended up groveling before Orrin Hatch seeking absolution for his sins against the free market. The story is actually mentioned in the NYT article, as is Hatch’s attempts to intimidate the Obama Administration’s nominee for commissioner of the FDA, Dr. Margaret A. Hamburg.

So long standing and blatant has Hatch’s advocacy been that ten years ago Stephanie Mencimer wrote a devastating article for The Washington Monthly entitled Scorin’ with Orrin, an accurate description of Hatch’s activities then and now. To this day, Hatch remains in the pockets of the supplement manufacturers, and he has served them well, passing the DSHEA, a law that has been exploited by Utah companies like Xango:

But Xango’s record illustrates how companies eager to exploit the law can go too far.

In 2006, federal regulators warned Xango that brochures improperly promoted mangosteen juice as a disease cure, not just a healthy option. Xango is among more than a dozen Utah companies cited by federal regulators over the last decade for apparent violations of the law.

Xango, whose executives are the single biggest Utah-based contributors to Mr. Hatch’s political campaigns and have drawn Mr. Hatch to its headquarters to down shot glasses of their juice, blamed a marketing company that had printed the brochures. The company also insisted that it was closely monitoring distributors to make sure they did not make inappropriate claims.

But in his talk at Xango in March, Dr. Johnson — who lectures across the country at other company events — used some of the same language the F.D.A. had cited in its 2006 warning letter, and he referred the sales agents to a nearby company that still sold brochures making the improper claims.

Amusingly, this NYT article also includes a truly mind-numbingly idiotic statement justifying the activities of certain supplement companies from Dr. Johnson, so much so that even our very own Steve Novella labeled it the “Dumb Statement of the Week.” I think it has a real shot of winning far more than that:

One night in March, Dr. Vaughn T. Johnson, a Xango distributor, delivered part pep talk, part medical seminar, in describing extraordinary powers attributed to mangosteen. Studies showed, Dr. Johnson said, it was “anti-tumor,” “anti-obesity,” “anti-aging,” “anti-fatigue,” “antiviral,” “antibiotic” and “antidepressant.”

“How do I know this isn’t just snake oil?” Dr. Johnson, an osteopathic physician, asked. “It’s a really simple answer. A company that is selling snake oil is not going to stay in business for almost 11 years and grow as fast as this company is growing.”

In other words, because his supplements sell well, they must work. Anyone familiar with evidence- and science-based medicine knows that this is utter nonsense on steroids (which adulterate quite a few supplements, by the way). Placebo effects, confirmation bias, expectancy effects, and a number of other nontherapeutic effects can lead to the success of a product. Before the FDA existed, there were countless useless patent medicine products sold in this country that were quite popular. Heck, homeopathy is still popular in some parts of the world, and it’s just water!

It is with great irony that, having read this NYT article, I note how advocates of unscientific modalities frequently love to bash big pharma and insinuate that legislators are in the pocket of the drug companies. While it is true that pharmaceutical companies are heavy contributors to a number of legislators and wield considerable influence, pro-CAM apologists frequently contrast what they paint as big, soulless, corporations with local, mom & pop “natural medicine” businesses that big pharma is supposedly trying to crush, all in a nefarious plot to protect its obscene profits. However, as Orrin Hatch demonstrates, in the wake of the DSHEA of 1994, in the U.S. supplement manufacturers have themselves become quite a force to be reckoned with themselves. In states like Utah, supplement manufacturers can become far more powerful than pharmaceutical companies. One reason is that there isn’t much in the way of a pharma presence, big or otherwise, in Utah. There are, however, lots and lots of supplement manufacturers pushing all manner of poorly supported health claims to sell their products. Because these supplement manufacturers are very profitable and have a lot of money to throw around, it’s not surprising that they now also have a very powerful patron, too, in Orrin Hatch. As long as Hatch is in office, you can be quite sure that the DSHEA will stand, and, if Hatch has his way, sooner or later its remaining tooth will be pulled.

The question then becomes: What will happen after Hatch retires? He is, after all, in his late 70s. Clearly, it’s likely (although not a lock) that Jason Chaffetz will succeed him. If that happens, he will be even more in the pocket of the supplement manufacturers than Hatch has been over the years. Chaffetz will, of course, not have the seniority and long years of having built up political power and capital that Hatch has right now; so at first he is unlikely to be nearly as effective a protector of the supplement industry as Hatch has been. Still, that might offer a window of opportunity. The only time supporters of more science-based regulations of supplements will have a chance to do away with the DSHEA will be in the immediate wake of Hatch’s retirement or death, before his successor can accumulate clout.

Even at that time, I’m not optimistic that the DSHEA will ever be repealed.

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Modern Website Design: Layout

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There have been many books written about website design, and I am not about to take on the challenge of disputing any of them or trying to explain every facet of design. In this short blog, I want to explain what I have come to understand as the modern layout of websites. The term “layout” may have many different definitions, but for this article I am talking about the basic structure of your website, meaning separation of concerns, data transfer from host to client, how to handle changes in data, and when to change your page structure.

Separation of Concerns

It is important when sitting down for the first time to build a website to come up with an outline. Start by making a list of the parts of your website and the functions of those parts. I always start at the base of my web structure and work from there. HTML is always the foundation of a website; it defines the structure and outlines how you will display your data – plain and simple. It doesn’t have to include data or styles, nor does it need to be dynamic … At its essence, it’s a static file that browsers can cache.

Client-side scripting languages like JavaScript will take care of client-side animations and data dispersal, while cascading style sheets (CSS) take care of style and presentation, and server-side scripting languages like PHP or Perl can take care of data retrieval and formatting.

Data Transfer

Where is your data going to come from, and what format it will be in when the client receives it? Try to use a data format that is the most compatible with your scripting languages. I use JavaScript as my primary client side scripting program, so I try to use JSON as my data format, but that’s not always possible when dealing with APIs and transferring data from remote computers. JSON is quickly becoming a standard data format, but XML* is the most widely accepted format.

I prefer to use REST APIs as much as possible, because they sends the information directly on the client, rather than using the server as a proxy. However, if a REST API is not available or if there is a security risk involved, you get the advantage of being able to format the data on the server before pushing it to the client. Try to parse and format data as little as possible on the client side of things, the client should be concerned with placing data.

Changes in Data

In the past, websites were made from multiple HTML documents, each one containing different data. The structure of the pages were the same though, so the data changed, but the code was nearly identical. Later, using server side scripting programs, websites became more dynamic, displaying different data based on variables passed in the URL. Now, using AJAX or script injection, we can load new data into a static webpage without reloading. This means less redundant code, less load on the client, and better overall performance.

Page Structure

It is important when displaying data to understand when to change the structure of the page. I start by creating a structure for my home page – it needs to be very open and unrestricting so I can add pictures and text to build the site. Once the overall loose structure is established, I create a structure for displaying products (this will be more restrictive, containing tables and ordering tools). The idea is to have as few HTML structures as possible, but if you find that your data doesn’t fit or if you spend a lot of time positioning your data, then it might be time to create a new structure.

The Impact of a Modern Layout

Following these steps will lead to quicker, more efficient websites. This is (of course) not a new subject, and further understanding of web layout can be found in Model-View-Controller frameworks. If you find that you spend too much time writing code to interface with databases or place data, then frameworks are for you.

-Kevin

*If you have to deal with XML, make sure to include JavaScript libraries that make it easier to parse, like JQuery.

Technology Partner Spotlight: Visualize ROI

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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 the guest blog from Mike Genstil of Visualize ROI, a SoftLayer Tech Marketplace Partner providing a flexible platform for enabling sales and marketing professionals to place ROI models on the web in an engaging format. To learn more about Visualize ROI, visit http://www.visualize-roi.com/.

Don’t Tell Me … SHOW Me the Numbers

We are living in a new world of increased corporate accountability and frugality. Thanks to unpredictable markets and unscrupulous leaders, the stakes have been raised in corporate decision-making. We have entered an “ROI revolution,” where CFOs, CMOs, and CIOs are demanding detailed business cases before they will make a purchase. Questions asked of vendors by executives are, “What is the Return on Investment?” and, “What is my Total Cost of Ownership?”

Based on our research, less than 5% of companies that sell into B2B environments have an effective and efficient way of creating engaging, credible business cases for customers. Most companies that sell to businesses have developed some type of spreadsheet-based “ROI calculator” to help salespeople and customers understand the ROI. Best-in-class companies often have created multiple models – one for a “business case,” one for “a competitive comparison,” and one for “persona-based selling.” Unfortunately, these spreadsheets are not effective for several reasons:

  • They are confusing and not easily modified
  • They suffer from version control issues
  • They don’t integrate with existing CRM and marketing automation systems
  • They don’t easily enable the creation of scenario comparisons
  • They can’t create professional looking reports

VisualizeROI solves these problems … and more. VisualizeROI is the first SAAS-based approach to business-case selling. We launch web-based Visualizers in days, integrate with existing systems and capture a rich set of prospect data that allows management to do analysis of customers and prospects that just isn’t possible today. Salesperson customization options are available, and salespeople can be notified when customers do their own analysis. It’s addictive.

To get an idea of the flexibility and functionality a “Visualizer” can provide, check out the Drive vs. Fly? Visualizer I mentioned in the video with Kevin. To see business examples, you can head to http://www.visualize-roi.com/examples/ to see a few of the Visualizers we created to feature the platform.

If you already have your ROI model and you want to make your own Visualizer, we’re ready for you: http://www.visualize-roi.com/create/!

-Mike Genstil, Visualize ROI