Earlier this spring, I described the Choosing Wisely campaign in the United States, an initiative designed to redirect resources away from medical treatments that are useless or harmful. In the spirit of the campaign, I suggested Five Things Pharmacists and Patients Should Question. My list included unvalidated IgG food intolerance blood tests like Hemocode, dubious “Body Chemistry Balancing”, inaccurate heel ultrasound bone density testing, and saliva hormone testing. I also singled out breast thermography as a particularly questionable test that pharmacies offer. Cancer tumours need a rich blood flow to grow, so cancer cells secrete chemicals to stimulate the development of new blood vessels. More blood flow means warmer tissue. Thermography, sometimes called digital infrared thermal imaging (DITI) uses infrared measurement to detect skin temperature differences. Thermography has emerged as an alternative therapy offered by naturopaths, homeopaths, and some health professionals, like pharmacists. Note the claims made: Continue reading
I’ve been calling on pharmacies to stop selling homeopathy since my very first post, almost (gulp) four years ago. Despite looking like medication, homeopathy is an “alternative” medicine system invented in the 1800′s which rejects established facts about biochemistry, physics, and pharmacology. If homeopathy works, then the rest of medicine we rely on could not work. To be perfectly clear, there is no serious scientific debate about homeopathy. It is inert. Yet pharmacies sell it side-by-side with other medicine, and are routinely ridiculed for it.
“There is no medicine without medicines” write Ben Goldacre in his new book Bad Pharma. To Goldacre, an author, journalist and physician, this cause is personal. The title, a reference to both his first book, Bad Science, as well as the pharmaceutical industry’s nickname Big Pharma, is a bit of a misnomer. While the focus is pharmaceutical companies and their actions, there are a number of enablers in the health care system – medical journals, regulators, and even medical professionals, all of whom have put the industry’s needs ahead of good medicine. According to Goldacre, the damage is pervasive and deep, right to the roots of modern medicine. These problems know no borders, and affect us all. Despite the different health care systems that exist worldwide, we all depend on for-profit pharmaceutical companies to develop and market new medicines. These companies collectively wield enormous clout, due in part to the remarkable success of medicines over the past several decades. The global pharmaceutical market will probably top $1 trillion (yes, 12 zeros) this year. And Goldacre argues the industry is not only compromised, it is broken. And over 400 pages, he defends the following paragraph:
Drugs are tested by the people who manufacture them, in poorly designed trials, on hopelessly small numbers of weird, unrepresentative patients, and analysed using techniques that are flawed by design, in such a way that they exaggerate the benefits of treatments. Unsurprisingly, these trials tend to produce results that favour the manufacturer. When trials throw up results that companies don’t like, they are perfectly entitled to hide them from doctors and patients, so we only ever see a distorted picture of any drug’s true effects. Regulators see most of the trial data, but only from early on in a drug’s life, and even then they don’t give this data to doctors or patients, or even to other parts of government. This distorted evidence is then communicated and applied in a distorted fashion. In their forty years of practice after leaving medical school, doctors hear about what works ad hoc, from sales reps, colleagues and journals. But those colleagues can be in the pay of drug companies – often undisclosed – and the journals are, too. And so are the patient groups. And finally, academic papers, which everyone thinks of as objective, are often covertly planned and written by people who work directly for the companies, without disclosure. Sometimes whole academic journals are owned outright by one drug company. Aside from all this, for several of the most important and enduring problems in medicine, we have no idea what the best treatment is, because it’s not in anyone’s financial interest to conduct any trials at all. These are ongoing problems, and although people have claimed to fix many of them, for the most party they have failed; so all of these programs persist, but worse than ever, because now people can pretend that everything is fine after all.
We all have our own biases, and I should disclose mine. I’m a pharmacist who has seen HIV go from a death sentence to a chronic disease, thanks to newly developed drugs. I’ve watched cancers like leukemias be effectively cured, thanks to medication. And I’m amazed that surgeries like double-lung transplants, impossible in the past, are now a reality, thanks in part to drug treatments. Yet I’ve also spent more than a decade reviewing the efficacy and safety of prescriptions drugs. Regrettably few are truly innovative. Many are approved with lingering questions about long-term safety and effectiveness. The value some offer can be questionable. I’ve also seen tremendous harms caused by drugs – from individual patients who have suffered horrible adverse drug reactions to population-level disasters like the Vioxx (COX-2) debacle. And I haven’t ignored the countless fines levied on pharmaceutical companies for bad, and sometimes even criminal, behavior. With its repeated capacity for self-sabotage, the pharmaceutical industry is its own worst enemy. My colleagues who work in the pharmaceutical industry agree. They’re smart, honest people that genuinely want to help get good treatments to patients. They’re embarrassed by what they see. So while I have no doubts about the astonishing track record of innovative new drugs that have transformed medicine, I also have no illusions that drug companies always behave in ways that support science-based medicine. And I think there is the potential for the industry to do much better. So how do we get this? Continue reading
Articles, posts and content of interest to the science-based reader: Continue reading
It’s nice to be acknowledged for your work, even if it’s just for creating 140 character messages. James Fell who writes for Chatelaine magazine and is also active on Twitter, recently published a list at Chatelaine: The Ten Best Health Experts to Follow on Twitter. And guess who made the list?
I’ve been using Twitter for a few years now and find it’s a great tool for learning, educating, and connecting with people that share similar interests. If you like the blog and wish I’d update it more frequently, follow me on Twitter where you’ll see a lot more relevant content that I just don’t have time to blog. I’ve got a fair number of followers and follow about 500 people – a mix of scientists, science writers, journalists, health professionals, and more. I’m not surprised by some of the other “best health experts” on James’ list – I already follow Julia Belluz, André Picard , Yoni Freedhoff and Timothy Caulfield, and you should too. If you’re not already using Twitter, check it out. What happens on Twitter right now is today’s newscast and tomorrow’s newspaper.
Science-based health professionals hold the scientific method is pretty high regard. We advocate for evaluations of treatments, and treatment decisions, based on the best research. We compile evidence based on fair tests that minimize the risks of bias. And we consider this evidence in the context of the plausibility of the treatment. The fact is, it’s actually not that hard to get a positive result in a trial, especially when it’s sloppily done or biased. And even when a trial is well done, there remains the risk of error simply due to chance alone. So to sort out true treatment effects, from fake effects, two key steps are helpful in reviewing the evidence.
1. Take prior probability into account when assessing data. While a detailed explanation of Bayes Theorem could take several posts, consider prior probability this way: Any test has flaws and limitations. Tests give probabilities based on the test method itself, not on what is being tested. Consequently, in order to evaluate the probability of “x” given a test result, we must incorporate the pre-test probability of “x”. Bayesian analysis uses any existing data, plus the data collected in the test, to give a prediction that factors in prior probabilities. It’s part of the reason why most published research findings are false.
2. Use systematic reviews to evaluate all the evidence. The best way to answer a specific clinical question is to collect all the potentially relevant information in a structured way, consider its quality, analyze it according to predetermined criteria, and then draw conclusions. A systematic review reduces the risk of cherry picking and author bias, compared to non-systematic data-collection or general literature reviews of evidence. A well-conducted systematic review will give us an answer based on the totality of evidence available, and is the best possible answer for a given question.
In order for our evaluation to factor in prior probability, and to be systematic, we need all the evidence. Unfortunately, that’s not always possible if evidence remains unpublished or is otherwise inaccessible. There is good evidence to show that negative studies are less likely to be published than positive studies. Sometimes called the “file drawer” effect, it’s not solely the fault of investigators, as journals seeking positive results may decline to publish negative studies. But unless these studies are found, systematic reviews are more likely to miss negative data, which means there’s the risk of bias in favor of an intervention. How bad is the problem? We really have no complete way to know, for any particular clinical question, just how much is missing or buried. This is a problem that has confounded researchers and authors of systematic reviews for decades. Continue reading