A naughty boy did it and ran away
And so Andrew Wakefield wanders off into the land of infomercials, loopholes in labelling regulation and other places where purveyors of rage-based medicine hang out. And the assorted Ben Goldacres and similar of the medical profession and skeptical hobby community use it as the occasion for yet another bout of Lisa Simpson moralising lectures on that awful media, and those dreadful gullible people who believe the media, and isn't it all so infuriating that people aren't rational, like us? I blame the media.
Except ... actually, that attitude is really a big part of the problem itself. Nothing makes people keener on medical science and evidence-based approaches than receiving compassionate, respectful, effective treatment by the medical profession. Nothing sells them quicker on woo than the kind of experience most parents of autistic kids get. Same with chronic fatigue syndrome and allergies - doctors all too often just grunt at the patients, good as call them malingerers and shunt them out the door, then wonder why it is that homeopaths sell so well. Even the dreaded chiropractors basically make their living out of poor soft skills in the treatment of back pain. The media isn't creating the demand for woo - it's responding to a demand created by the medical profession's failure to provide the kind of treatment patients need.
Nah, not worth thinking about. After all, doctors didn't go through eight years of medical school just to be nice to people! And it's certainly a waste of sacred NHS money to spend five minutes smoothing over whining patients precious ickle feelings! Fuck 'em all. If only they were rational, objective and above all well, like me, they'd be able to buck up and stop making fools of themselves. Now let's all have a good old laugh at the Daily Mail.
Goldacre's whole shtick in "Bad Science" is that he has the ability to read a scientific paper and tell you the difference between what the scientific paper says and what the Daily Mail says it says. Not a bad idea. Based on my long experience of reading the texts of papal addresses and then reading sincere people's furious reaction to something B16 didn't say, I'm thinking of starting a "Bad Religion" service.
ReplyDeleteAnyway, Goldacre of course is not a working scientist but a hospital doctor, as is Evan Harris. It's a profession known for its peremptoriness, and hospital doctors are also used to being deferred to. If chiropractors behaved like hospital doctors, they'd have no customers at all and Simon Singh could rest easy.
Interesting point - when I go, as I occasionally do, to a sceptics' event, I notice very few scientists but lots and lots of media types. Strange.
doctors all too often just grunt at the patients, good as call them malingerers and shunt them out the door
ReplyDeleteIt's a profession known for its peremptoriness
No possibility, I spose, of any actual evidence being adduced for this stuff?
If chiropractors behaved like hospital doctors, they'd have no customers at all and Simon Singh could rest easy.
Whereas, if hospital doctors behaved like chiropractors ...
My experience as an observer of relatives in hospital (never been a patient) is that it's the doctors who are useful and helpful - they're the ones who do the curing that gets done. It's the soft-skilled nurses who are thoughtless, ignorant and stupid-rude.
Naah, this is mostly bollocks. The main problem is that, when people go to the doctor with a problem, they want a pill that will make it all better. In many cases they will get just that, such are the successes of medical science, but for many conditions, there is no known cure and perhaps only a vaguely understood cause. In these cases, medical doctors offer some alleviation of symptoms and some general lifestyle advice (lose weight, drink less, watch your posture, whatever), which many patients find unsatisfactory, while the woo-peddlers offer a magic pill that will make it all better.
ReplyDeleteI agree with Iain. There's not many professions ruder or more peremptory than hospital consultants (and absolutely don't start me on consultant psychiatrists) but I don't for a moment believe that they're the reason people go to charlatans.
ReplyDeletebut hang on, most charlatans don't offer magic pills do they? lots of them offer time-consuming all-encompassing lifestyle-choice thingys.
ReplyDeleteI think Iain is being unduly charitable to the medical profession.
ReplyDeleteMy own experience of both chronic conditions with known causes and treatment [joint problems, sports injuries, etc] and less common and/or acute conditions is that you'll need to bug your GP several times over, and after the third or fourth iteration of 'take some ibuprofen and stop doing whatever it is that be causing it'* they might deign to refer you to someone who might be able to do something about it. But, even then, it might take several iterations of that before anyone will be prepared to do anything that might cost money.
It's true that doctors offer general lifestyle advice, and sometimes that's sincere and well-meant, but often that's instead of offering whatever treatment or investigation might be needed. It might well be cost effective to keep fobbing people off until they won't put up with being fobbed off anymore. It's a system of rationing and, I suppose, persistence in the face of being fobbed off might be one way of identifying the more serious cases. I'm not against health-care rationing of various kindsm, but people aren't stupid. They know they are being fobbed the fuck off, and they don't like it.
* the 'take ibuprofen and stop doing it' advice being particular amusing when 'it' is one's job, and when one can't actually take ibuprofen for medical reasons.
1. I think it would, in general, help the medical profession if the "placebo effect" were treated, not just as a way of being suspicious of evidence, but as a valuable medical benefit to be sought after. Studies of alternative medicine (at least the ones I've seen) seem focused on proving that it's all snake-oil that "only" helps by the placebo effect, but really, pure snake-oil should be the perfect natural experiment for figuring out how best to produce the placebo effect (e.g., what is it that makes one acupuncturist more effective than another, if it's not the placement of needles? Is it something that doctors could imitate, in providing "real" medicine?)
ReplyDelete2. In the US, at least, it does not help that doctors are, on some occasions, actually trying to sell their patients expensive and dangerous treatments. I know one woman who frequently posts on Facebook about how people shouldn't vaccinate their kids, which is of course terrible advice; but she also posts about how people should not trust their doctors when they recommend C-sections. About the latter she's absolutely right, she's speaking from personal experience, and it's not surprising that, as a result, she is unwilling to buy arguments along the lines of "trust your doctor, he knows what's best for you."
With all due respect, this is a bit of a strawman. There is no contradiction between demanding less bullshit and demanding better doctoring. In fact, the two are elements of the same thing - the recognition of bullshit, and its rejection.
ReplyDeleteAs it happens, Wakefield didn't make a reputation for being really nice; he made a reputation for offering what he claimed to be a monocausal technical diagnosis, and would have offered a (incredibly dangerous and ill thought out) one-shot drug fix had he been able to get away with it. Further, rather than being terribly nice, etc, etc, he's a fucking general surgeon, the most hospitalist, authoritarian, hyperconfident specialisation in medicine.
Also, the platonic-ideal old fashioned GP with a great bedside manner was a terrible quack. The UK's rate of deaths in childbed remained far higher than any other developed country long after Lister because the buggers wouldn't wash their fucking hands; that only changed when Bayer launched prontosil in 1935 and they could administer a pill. The stereotype GP voted against the NHS, too...
Anyway. Firstly, it is worth going after Wakefield and such because they are net contributors to world bullshit. The general anti-bullshit principle applies.
Secondly, there is at least an argument that gullibility is fungible - the more people learn to believe in things that can't possibly be right, the more such things they'll believe in.
Thirdly, a small but nontrivial percentage of the market for woo will actually manage to endanger themselves or others. There may not be many, but the consequences can be horrible (especially as experimenting on one's children is a common failure mode), and society makes quite a lot of effort to stop fairly rare (but horrible) accidents in many other fields. It is uncontroversial that drug manufacturers are responsible for the effects of their products, however unlikely.
Fourth, the purpose of a system is what it does. So long as woo handles real medicine's emotional requirements, real medicine won't improve on this - and in fact, some individual medics will profit by indulging in quackery on the side. Similarly, the UK market for woo in a sense represents an externalisation of the costs of the historically shitty GP sector, as does part of the central NHS budget. And see arguments 1 and 2.
Fifth - a special US argument - if part of the problem is that doctors are incentivised to sell their patients treatments, you really don't want them selling things that don't have to pass the FDA approval system. It was in the States that people and their doctors have killed their autistic kids by chelating all their blood electrolytes out.
Good post. And one element of treating your patients like human beings and not wastes of your highly qualified time is bothering to explain what's wrong with them and how your proposed trratment will work. Quack treatments do just this: provide a narrative around the patient's negative experiences, letting them feel in control of their own bodies again. As long as doctors guard their medical knowledge (taught them by the state I might add) so jealously, it will remain a less attractive/less persuasive offer than the juju pills.
ReplyDelete"Nah, not worth thinking about"
ReplyDeleteI've not got it to hand to check but I'm pretty sure Goldacre makes the same point as you in his Bad Science book.
@Alex, WIN.
ReplyDelete@Ben, yes, he does.
Surely what you really want for back pain is not for your GP to be all nice and caring to you, but for him to refer you to a physiotherapist?
ReplyDeleteI don't think it is a strawman at all. I'm not supporting Wakefield at all, or saying it was wrong to strike him off. I'm making the point that this ought to have been a good occasion for the medical profession to think about what they might have done better and prevented this clusterfuck. Instead they, including Goldacre, did what insular and self-satisfied professions always do when they're faced with a megafuckup - they blame it all on the bad apple, and then bemoan the fact that the media never give them a fair hearing.
ReplyDeleteAt present, the anti-bullshit strategy is about as mindless as it can be - it's based on arguing with the customer and presuming that if we all shout "THAT'S BULLSHIT!" loud enough, and hand each other enough science journalism awards, then one day the masses will see the light. Basically, the Richard Dawkins approach to proselytisation.
And frankly, the current approach to combatting the anti-vaccination movement has been given a fair run out and is failing really badly. Ironically, in the third world someone charged with carrying out a vaccination program who found that parents were much more responsive to single vaccinations than triple vaccinations wouldn't have spent even a second on trying to argue with the customer - they'd have gone with the version that had the best take-up, even if doing so did make baby David Hume cry.
There's a real problem here (and with respect to CFS, allergy medicine generally, back pain and, as Justin notes, psychiatry). The way the medical profession is organised is such as to underemphasise "soft skills", because they can't be tested on a very difficult examinsation and are thus potentially a source of gayness.
The narrative that's being constructed here is really unhelpful, because it's one in which the vaccination rate went through the floor, but this wasn't the fault of the people running it, no sirree - hence the title of the post. There's no inquiry into why the news media were so keen to take Wakefield's side, or into what could be done differently; there hasn't been an inquiry into anything other than Wakefield personally, which took some time out to have a go at the media.
By the way, all you Twitter kids (by which I mean John), I am very close to developing an official policy on the use of the "@" symbol. Simply a name will do, thanks.
ReplyDeleteGiven the doctors are notoriously bad at statistics, probability and understanding scientific experimentation, i've always found the Bad Science stuff amusing. Physician heal thyself.
ReplyDeleteNo, you're just having another round of your long-running argument with a straw Ben Goldacre whose writings differ quite a bit from the other one's, and it's actually quite boring.
ReplyDeleteAnd, to repeat, Wakey didn't offer anything in the way of "soft skills". More like "science-bit guff, promises of a one-shot technical fix, and some quite painful and invasive medical interventions". There is nothing soft about a lumbar puncture.
Wakefield did actually give autistic parents a much more respectful and receptive hearing than the NHS was prepared to at the time, which is why they flocked to him and asked him to be their expert witness. He apparently wasn't an easy person to work with according to his colleagues, but the parents in his autism study gave loads of interviews, and their common thread was that Wakefield was the only person who would listen to them. This was unfortunately because he was trying to use them for his own purposes, but it's really sad to recognise that they hadn't got that from anywhere else.
ReplyDeleteAnd I've just checked the Goldacre site and I don't agree that I'm dealing with a strawman rather than the real thing. The second headline down is entitled "The Ancient And Noble Art of Moron-Baiting" (it's actually an obituary of Martin Gardner, but the headline sums up my problem with Goldacre so utterly perfectly).
And his article on the Wakefield MMR verdict does exactly what I said above - the blame splits 50/50 between Wakefield himself and "the media". Goldacre was clearly worried that I might be accused of arguing against a straw version of him, so he made sure to say so specifically:
"He is a bad man and he shares half the blame, the other half is discussed here: (link to an article discussing the media)."
And it's certainly a waste of sacred NHS money to spend five minutes smoothing over whining patients precious ickle feelings! Fuck 'em all.
ReplyDeleteI don't know about the rest, but I have certainly heard Goldacre make the diametrically opposite argument to this one.
- Larry T
I wouldn't be surprised if he has - there is, after all, a lot of evidence that it's the correct thing to do and I'm sure he's come across it given I have. But, in respect of Wakefield (and in every other specific case where I've checked up on Goldacre), res ipsa loquitur - as a matter of observable fact, he doesn't recognise that there might have been anything wrong with the medical establishment's response to worried parents. Also, look at the tag list on his blog - there's about two dozen different ways of calling other people morons, a whole category for "psychology of woo" but nothing at all about gp malpractice.
ReplyDeleteI mean, check out this post. It's about a very sensible Australian public health campaign on back pain. Goldacre doesn't waste even a word on "why on earth don't we do something like that here?". It's all "hurray scientists and rationalists and boo to humanities graduates, whose fault back pain is in some way". Very specifically, he is talking about this issue, but his approach isn't at all to recommend that doctors spend some time and effort on learning the best way to give advice for back pain sufferers - he's just saying that the problem is everyone else's fault for not doing exactly what they're told by doctors.
It seems to me you're drawing too close a connection between blogging rudeness about woo, and GPs taking an appropriate attitude to patients' precious ickle feelings.
ReplyDeleteI can see your argument that there might be some link between the two, in the medical profession as a whole. But they don't seem to be closely connected - or indeed connected at all - in Goldacre's case. He blogs against practitioners of woo (which is fair enough, per se, and not the same as blogging against the consumers of woo). At the same time he does devote time to encourage scientists and medics to pay closer attention to the placebo effect. In fact, he calls it "one of the most effective and neglected evidence based treatments known to man".
(Maybe you read it differently, but I see "why on earth don't we do something like that here?" as implicit in a blog post drawing attention to "paper showing that a simple public health campaign, encouraging people to get back to action as soon as possible, reduced the prevalence of back pain in a population".)
- Larry
Daniel, due to the word limits inherent in writing a regular newspaper column, Goldacre usually focuses on evidence from studies, or more frequently, the lack of evidence that exists for a claim due to poor or no studies. He doesn't so much do speculation.
ReplyDeleteThe study he reported on there wasn't about how to frame the advice, or how to speak nicely to your patients, or how to be approachable - it was about *what advice or treatment was most effective for back pain*.
I'm sure if there are any studies looking at the former, he'd be grateful if people brought them to his attention.
I don't think there's any question that financial incentives for GPs to see many patients *do* pervert the NHS consultation process - but in terms of more specific questions like "how best to say your back pain is not a medical problem and you need to avoid taking a break from work" it's not so clear, and indeed the idea that back pain *needs* to be demedicalised arguably goes against the thrust of your argument. Sometimes - in fact, GPs would argue, a great many times - patients come to GPs with problems which are not, or should not be, considered medical problems at all, and along with being sympathetic where appropriate it *is* a part of a GP's job to tell hypochondriacs the truth and tell those of us who don't need a pill that yes, we really don't need a pill.
In fact, he calls it "one of the most effective and neglected evidence based treatments known to man".
ReplyDeletemy problem with the guy is that this is where his analysis starts and stops - as far as I can see he (and he would be entirely typcial of British doctors in this regard) views the PE as being basically a means whereby gullible patients are fooled, and the only issue to discuss as being the ethical and practical dimensions of fooling them.
In fact, British doctors practice an awful lot of anti-placebo effect, by treating their patients with exactly the patronising, offhand manner that Goldacre exemplifies in his "Baiting Morons" posts and jounalism. The precise mistake here is in assuming that "the placebo effect" is another treatment you can use, rather than something that's intrinsic to an overall relationship between patient and doctor. Specifically, the issue here is exactly the one that the "holistic" crowd talk about (Edzard Ernst is very interesting on this topic).
And every time something like this is raised (ie, something which would actually potentially call into question the nature of the social relationship between doctors, scientists and the rest of society, specifically by taking the former down off their pedestal), Goldacre starts talking about "humanities graduates" and the like. It's not actually very helpful, just as the Dawkins/bacai/"anti-accomodationist" approach isn't helpful as a starting point for a discussion of religion.
I personally look at woo medicine as being really rather similar to recreational narcotics - in general they're bad and usually sold by quite unpleasant people. But the question to ask isn't "how can we suitably demonise these evil peddlers?" but rather "what is going wrong in our system which means that so many people see this as the best available solution to their problems?".
Sometimes - in fact, GPs would argue, a great many times - patients come to GPs with problems which are not, or should not be, considered medical problems at all, and along with being sympathetic where appropriate it *is* a part of a GP's job to tell hypochondriacs the truth and tell those of us who don't need a pill that yes, we really don't need a pill.
ReplyDeleteand in a great many cases, GPs do this with a healthy dose of BACAI (which is not a placebo), and "being sympathetic where appropriate" is really the entire issue here. It's a social convention that GPs (and other doctors) are allowed to speak to their patients de haut en bas in a way in which no other professional would ever do. This social fact has real medical consequences (which are regularly investigated and established by some of the best medical science). It would be much better if doctors behaved more like, say lawyers or accountants talking to their clients, or even like teachers talking to their pupils. But they don't want to, and Goldacre seems to me in his writing to be strongly and implicitly in favour of maintaining this social convention the way it is now (cf "humanities graduates" - even if you've got a university education, you don't deserve to have your views respected). And in his broader journalism, he's still of the "I tell, you listen" school of science communication, which doesn't work and is known not to work.
It would be much better if doctors behaved more like, say lawyers or accountants talking to their clients, or even like teachers talking to their pupils.
ReplyDeleteThat would only work if you're prepared to employ enough extra GPs so you can offer half an hour slots to most patients and patients can still get appointments within a day or two. Some of the brusqueness is that they have 5-10 minutes for most appointments, so the emphasis is on quick diagnosis and solution. On the other hand, if you're a lawyer charging by the hour, five minutes of pleasantries with the client means an extra ten pounds or more on the bill...
he (and he would be entirely typcial of British doctors in this regard) views the PE as being basically a means whereby gullible patients are fooled, and the only issue to discuss as being the ethical and practical dimensions of fooling them
ReplyDeleteNo, you might be right about his journalistic style, but you're really doing him an injustice here, I think. Truly! Watch this.
Aren't you and he actually on the same page?
Larry
I certainly agree that the Youtube video was a lot better than his journalism or his blog (I think I've heard him deliver a similar speech at a stand up comedy event), but even there, I don't agree I'm on the same page. For one thing, there's still a lot of trying to avoid being associated with the dirty-fucking-hippies equivalent - it's all "not in a wishy washy way" or "not in a New Age way". Actually there's only one way to be genuinely interested in and respectful of people, isn't there?
ReplyDeleteAnd secondly, it's still very much based in the way of thinking - we're the doctors, and we're deciding how we're going to treat you. If that's the way you're organising it - ie, that dealing with patients is an optional extra, an add-on that might make your treatments work better - then it's not surprising that it gets dropped for the reasons that Robin outlines when budget and time constraints bite. When all the evidence suggests that this is a total false economy - not only is this dimension probably one of the most important, but if you listen to people and deal with them as human beings the first time, you're just as likely to find that they don't need to keep coming back as much.
So with respect to whether I'm doing him an injustice ... well, I'd agree that he's a lot better than the run of the mill of self-styled "sceptics" - I focus my attention on him precisely because I think it's important to go for strong targets rather than weak ones, otherwise I'd be the proprietor of "Oliver Kamm Watch". But the fact that from time to time he recognises these things makes it even more infuriating that he spends so much of his time and effort on things that matter so little and on writing things that directly encourage the frame of mind that makes it more or less impossible for him to achieve his goals. Seriously, what do you think happens when an old lady who has a bit of joint stiffness walks into her GP's office and says that evening primrose oil is the only thing that keeps her mobile? If the GP is a big fan of "Bad Science", is he likely to give her the sort of experience Goldacre's talking about in that Youtube video?
sorry, erratum - in respect of bugetary and time constraints, for "Robin", read "Magistra" above.
ReplyDeleteGoldacre doesn't waste even a word on "why on earth don't we do something like that here?"
ReplyDeleteI seem to recall a rather good essay on the notion that it is usually better to criticise things that are clearly idiotic than put forward your own halfbaked ideas. It can be found here.
I wasn't totally convinced at the time, and I don't expect you to be religious about stuff you blogged in 2006. Perhaps you could do a tour de force 2500 worder on Crooked Timber or CIF about Aussie back pain treatment? I'd read it.
Please, though, no more "I'm a hardboiled Popperian, except on this pet issue where I demand that everyone else produce a fully costed draft Bill to Improve the World 2010 before they can have an opinion".
Now, if you (or anyone else) were to start a blog called Hang The GP, I'd be more than supportive. I suspect you might get support from all sorts of people.
Also, regarding Aussie back pain, he quotes great chunks of it favourably, further quotes vast lumps of the conclusion on how well it worked, and advises his readers to read the paper on the grounds that they are likely to have a bad back. This is getting into Amnesty rule territory.
ReplyDeleteDon't you think it's weird though, that Goldacre found something that had worked in Australia and which fit perfectly into the general project outlined in Larry's Youtube video, and his reaction to it was "haha, this shows what idiots arts graduates are for ever criticisng doctors, also those patients are so ungrateful when you tell them the real man's truth"? Particularly given that this is actually Goldacre's specific area of expertise - ie, public health and communication about medicine - and therefore one in which even by the standards of my 2006 essay, he would be ideally placed to do something about?
ReplyDeleteI don't think you're being very consistent here and you're being rather personal - what's up mate?
I mean specifically, his concluding paragraph:
ReplyDeleteThere is a fascinating irony here. While the flaky humanities graduate commentators in the media bang on about “scientism” and accuse doctors and scientists of being “reductionist”, while CAM therapists bang on about doctors being in the pocket of big pharma, and praise themselves for being “holistic” and “lifestyle oriented”… doctors seem to be the ones actually dishing out basic, sensible, evidence based non-technical lifestyle advice, and people are strangely resistant to hearing it.
The context was one in which a study had proved that the normal medical treatment performed not only worse than acupuncture, but worse than fake acupuncture. This would surely suggest that something was really badly wrong with the way that lots of doctors were dealing with back pain. Goldacre saw this result, cross-referenced it with something he'd seen elsewhere about how conventional medicine could be done much better and his conclusion was - a) yahh boo and b) this shows that "doctors" are all right really.
This is just a load of preaching to the converted, while treating the unconverted as basically objects of ridicule. The whole "sceptic" movement is full of it and it's amazingly unedifying.
I still reckon that you're conflating his public 'scepticism' with his recommendations for good medical practice, the latter of which seem a lot closer to your own than you're admitting. You might think he doesn't push that line of thought far enough, but the accusations you've levelled at him here have been a little more severe than that (see final paragraph of the post, or that he the suggestion that he "views PE as being basically a means whereby gullible patients are fooled, and the only issue to discuss as being the ethical and practical dimensions of fooling them"). I don't think these charges stick, and I think he does a lot better on this scale than the allowance that "from time to time he recognises these things".
ReplyDeleteYour broader point is that public 'scepticism' indirectly promotes unsympathetic medical practice. Maybe, but it'll be pretty marginal, I'd guess. To someone who thinks that widespread woo can pose a real danger to a society, the trade-off is probably worth it. Most of the sceptics' rage is directed at the distributers and propagandists of woo, rather than the consumers, and I don't see much reason to pull punches. But isn't this stuff that reasonable people can disagree over?
So to answer your question about the old lady, it depends how thick the GP is. If he's an idiot, he'll probably scoff at the poor old bag's credulity, pour scorn on her only source of comfort, and send her packing. On the other hand if he's that much of a moron, he's quite likely to fuck her over one or another anyway, no matter what blogs he reads...
Larry
bitheway, a quick glance at the paper linked reveals a rather ... interesting choice of success metrics:
ReplyDeleteThe campaign successfully managed to:
* "de-medicalise" a public health problem;
* ease the burden on general practitioners and specialists;
* empower workers to solve their own health challenges;
* and save workers' compensation payments.
Conspicuously absent - did it actually help the poor buggers with the pain? This is presumably a speed-reading or similar error, but Goldacre actually says that the paper shows that the Victoria campaign reduced the prevalence of back pain in the population and the paper absolutely does not make that claim - it's really careful not to.
(I note, slightly hilariously, that the BMA paper cited also has "Consider spinal manipulation [ie, chiropractic -dd] for pain relief" as one of its treatment recommendations. This again can't be blamed on Goldacre because it's not his fault that the evidence-based medicine movement is flapping in the wind with respect to chiro, but it's surely worthy of note).
I still reckon that you're conflating his public 'scepticism' with his recommendations for good medical practice
ReplyDeleteNo quite the reverse - specifically what drives me mad is that he doesn't seem to recognise any connection between the two; he doesn't seem to realise that the first is completely inimical to the second. I would agree that Goldacre is better than most of the rest of his journalistic industry because he does reasonably regularly take on a couple of difficult targets in the pharmaceutical industry, but as I say above - I'm not interested in attacking weak targets.
I don't agree with you that he does always, or even regularly, stick to attacking the producers of woo as opposed to the consumers, and the specific context was his Wakefield posts, which are really complacent as regards the role of the medical establishment in that horrendous fuckup - in Goldacre's version, the only thing everyone did wrong was to not catch the bad apple early enough.
I take your point about the last paragraph as applied specifically to BG, but I don't think I'm going to change it. That might not be what he believes in his considered writing, but it's certainly the message conveyed, and if he (or anyone else) really believes that widespread woo is a serious danger to the public then they might want to question whether the approach they've been taking to combat widespread woo over the last ten years + since "Bad Science" was first launched is actually delivering results.
As a matter of interest, why HAS it taken fully 12 years from the lancet paper to Wakefield being struck off? Given that his activities created a public danger immediately, and it seems like his most egregious dodginess was in full effect from the earliest of them...?
ReplyDeleteAs far as I can tell, about eight of those years were spent waiting for the science to pile up to be absolutely sure that the MMR vaccine was safe (try finding a pre-1998 study that specifically addressed this question), and the remaining four are basically the due process of the GMC. He was severely disciplined in various other manners a while ago, but the ultimate sanction (in cases of this kind) takes a long time. Remember that it wasn't till 2004 that Brian Deer found out he'd been paid by a lawyer.
ReplyDeleteSpinal manipulation is not coextensive with chiropractic. It can be performed by physiotherapists.
ReplyDeleteBy far the most objectionable claims of chiropractors have to do with their claiming to be able to treat medical conditions unrelated to the spine, claims for which there is no evidence. There is some evidence that spinal manipulation is effective for reducing back pain.
Also, I suppose, along the same lines as this post, instead of just exposing racism and the lies of the anti-immigration movement, politicians and activists should try to engage with the *very real concerns* of people like Mrs Duffy, by say, pushing for withdrawal from the EU (that being the only way to stem the "flocking" of intra-EU migration to the UK). Right?
ReplyDeleteAnd instead of just exposing Nigerian advance fee frauds and the like, anti-fraud writers should examine why the legal get-rich-quick industries (e.g. gambling and stockbroking) are doing so *badly* at addressing people's *very real concerns* about attempting to getting rich very rapidly via legal means.
Sorry, cheap shots.
he doesn't seem to realise that the first is completely inimical to the second
ReplyDeleteI can see a criticism here that I might possibly be persuaded to agree with, but I think you're overstating the argument by some distance.
Also, it is true that there is a chorus of media voices who sound off about "scientism" in medicine, thereby propagandising for woo, consciously or not. So what you see as him distancing himself from the dirty-fucking-hippies, I'm inclined to interpret as him defending his profession from ideological attack.
Larry
Also, I suppose, along the same lines as this post, instead of just exposing racism and the lies of the anti-immigration movement, politicians and activists should try to engage with the *very real concerns* of people like Mrs Duffy, by say, pushing for withdrawal from the EU (that being the only way to stem the "flocking" of intra-EU migration to the UK). Right?
ReplyDeleteNo, wrong. But, and I think I've always been consistent on this apart from a few moments of rage, we do need to accept that the fact that loads of people belive that they have very real concerns about immigration means that there's something going wrong with our system; specifically, in my opinion, that our system doesn't look after the working class very well at all. The fact that neoliberalism and globalisation aren't delivering the goods for the working class is a genuine problem that politicians genuinely need to address, but they need to address it properly. That doesn't mean playing anti-immigrant politics, any more than having the medical profession do something about poor doctoring means handing out fish oil pills. But similarly, I don't think the Tom Friedman approach of just repeating that "globalisation brings benefits to all" works either.
And instead of just exposing Nigerian advance fee frauds and the like, anti-fraud writers should examine why the legal get-rich-quick industries (e.g. gambling and stockbroking) are doing so *badly* at addressing people's *very real concerns* about attempting to getting rich very rapidly via legal means.
you're reaching here, aren't you? Most writers about Nigerian advance fee frauds are consumer finance journalists, and do actually spend most of their time documenting the inadequacies of the mainstream investment industry. But this isn't really remotely comparable because unlike alternative medicine, get-rich-quick fraud is a minority and marginal phenomenon - in countries like Albania where a pyramid scheme went national and nearly everyone was involved in it, then yes, I think it was correct that nearly all the journalists who wrote about that scheme also put it into the context of a totally screwed post-Soviet economy in which there were no reliable savings vehicles.
I wonder if the claim that it reduced the prevalence of back pain is in the BMJ article, which is hidden behind a paywall? Going by the contents page, it looks like a review of different treatments and their success or otherwise, which would make sense.
ReplyDeleteLooking at the Victoria study, I think it's much more likely that this is just a mistake - they didn't set out to look into pain, they were interested in pain-related disability. That's interesting in and of itself and I have a degree of sympathy for the view that it's a sort of success to persuade people with back pain to get on with their life (on the basis that being in pain is better than being in pain and also incapacitated).
ReplyDeleteFWIW, my personal involvement in this is with respect to allergy medicine and it's sort of at 90 degrees to the woo issue - I've been fighting a low level campaign for the last eight or so years since my son was born, against the medical profession's absurd timidity with respect to prescribing hydrocortisone.
As far as I can tell, doctors in the UK learn at some point that hydrocortisone has side-effects, and then take away the message that hydrocortisone is powerful juju that must hardly ever be prescribed, and never at any meaningful concentration. I happened to find out that the opposite is true through a combination of pure luck, and money. But it's an instance in which the problem was definitely one of doctors not listening to the patients; there's not a lack of information or even understanding and most of the doctors I've argued with on this are able to correctly reel off the side-effects of topical ydrocortisone - they just seem to believe that the tradeoff between those effects and eczema is a decision for them to make, without anything more than token input from me and mum, let alone from the kid himself. Eczema and dermatological conditions make up some ungodly high percentage of the woo market and I can totally see why.
(btw, if you discuss this sort of thing on doctors' boards, never ever admit that you or a family member have had any sort of illness unless you like being patronised).
That may be a national medical culture thing - the French have a drastically different view of drugs in general, basically "want a pint of codeine with that? you will you will you will" vs "tshh, don't get addicted now".
ReplyDeleteThat's interesting in and of itself and I have a degree of sympathy for the view that it's a sort of success to persuade people with back pain to get on with their life (on the basis that being in pain is better than being in pain and also incapacitated).
Also, working on the principle that GPs are bungling sawbones who are as likely to harm their patients as they are to heal them, any plan that reduces their opportunities to do harm is welcome. I do mean it about Hang the GP.
...GPs do this with a healthy dose of BACAI (which is not a placebo), and "being sympathetic where appropriate" is really the entire issue here. It's a social convention that GPs (and other doctors) are allowed to speak to their patients de haut en bas in a way in which no other professional would ever do. This social fact has real medical consequences (which are regularly investigated and established by some of the best medical science)...
ReplyDeleteI have to say that this doesn't describe any interaction I've ever had with a doctor, and I'd be interested to see this research. IT professionals, on the other hand...
IT professionals, on the other hand...
ReplyDelete...have a similar reputation to doctors for BACAI among the laity. I freely admit that nobody has ever managed to stay awake through an accountant explaining the difference between UK GAAP and IFRS to figure out what their attitude towards clients is.
Haha I just this minute returned from a visit to my GP with the advice that I take vitamin D supplement = fish oil pills!
ReplyDeleteI am actually very pro the team that work at my local -- very urban, very multi-cultural -- health centre: as I was waiting I observed one (English) doctor carefully explaining something to an African woman in not bad French, and a (Scottish) nurse chatting to another patient in I think Portuguese (quality unknown). They have a tough row to hoe, and I think they are generally pretty good, in just the regard that DD is saying there is a general badness. But I am the world's biggest sadcase booster of the overall awesomeness of Hackney, so my acecdata is skewed...
After all, doctors didn't go through eight years of medical school just to be nice to people!
ReplyDeleteActually, medical students do have classes in being nice to people.
Actually, medical students do have classes in being nice to people
ReplyDeleteInvestment bankers have mandatory courses in professional ethics ...
They have a tough row to hoe, and I think they are generally pretty good
I think doctors are generally OK - in the same way that I actually think investment bankers are generally OK. But when they're bad, they're bad in specific ways, and the big issue is that as a group they're often very resistant to outside criticism, while internal criticism is too often a case of preaching to the converted and being ignored by the problem cases.
I'm not interested in attacking weak targets.
ReplyDeleteI'm sure I've seen you do Mad Mel on here.
Re: Alex on French doctors, there's a similar thing in Spain with antibiotics. Antibiotics with everything. Which is odd, because in the UK I was always given to understand that repeated use diminishes its effectiveness.
I knew one of the high-powered people who went over to Albania to rescue its economy after the pyramid business. I have to saw that he WACAI big-time, referring to them as "the most ungrateful people in the world". Granted I believe they didn't welcome him too kindly when he was there, but the spectacle of highly-paid Western professionals abusing extremely poor people for ingratitude was not a terribly attractive one.
Justin: Its the same in the US, and it used to be the same in the UK. I think doctors misuse of antibiotics over the years falls into the same category as a lot of the supplements people. Took them an amazingly long time to do proper research into whether it worked for all the things they used it for. But antibiotics is a mess generally, partly due to the poultry industry using various antibiotics as growth agents. Which is seriously fucked up.
ReplyDeleteMy distrust of the medical profession is ingrained from having had a brother who did not have allergies. Except that he did, and now would be clearly be categorised as severely allergic (we're talking near death with most foods). My mum had a huge fight on her hands, and for years got used to doctors telling her that it couldn't be real because it didn't fit whatever theory they half remembered from uni. The medical profession resisted for years dealing with allergies properly, or acknowledging its existence and it was only due to parents and (some) alternative practitioners that things began to change.
This distrust was then It wasn't helped by hearing my (very senior) relative remark that he preferred working in Africa as he could use more interesting surgical techniques. Naively I asked why he couldn't use them here... interest for the surgeon and the interests of the patient did not apparently coincide here... I have other stories...
Which is odd, because in the UK I was always given to understand that repeated use diminishes its effectiveness.
ReplyDeleteWell, it selects bacteria with antibiotic-resistant genes, which is...unwise. I think it's fair to say that nobody has ever been harmed by not feeling their toothache or whatever enough.
GPs used to be notorious for handing out penicillin as a substitute for talking to their patients, hence the constant reminders that antibiotics will do nothing for your common cold.
Well, it selects bacteria with antibiotic-resistant genes, which is...unwise.
ReplyDeletein respect of which, I saw a couple of weeks ago but forgot to blog that the runaway success of Monsanto Roundup Ready corn, and consequent runaway success of Monsanto Roundup herbicide, has granted the world the added bonus of ... glyphopsate-resistant pigweed! Who could have known!
he preferred working in Africa as he could use more interesting surgical techniques
ReplyDeleteThe classic paper here is Jeffrey's "Normal Rubbish", on the way A&E doctors talk about (and classify, and deal with) the people who come through their doors. ("If there’s anything interesting we’ll stop, but there’s a lot of rubbish this morning." "We have the usual rubbish, but also a subdural haemorrhage.") 'Good' or 'interesting' cases were the ones that required them to think on your feet or to use new and different techniques. Or you could say, less sympathetically, the ones that allowed them to play around a bit.
Normal Rubbish. I recall having competitions with my brother a few christmases ago about whose profession had the more unpleasant and crudest slang.
ReplyDelete(gosh, what a find, thanks Phil - it's actually a very fair article and understated in the implicit criticism of the medics, while recognising the human and institutional pressures which make it basically impossible for them not to use this sort of categorisation).
ReplyDeletea late claim for journalism: "Anyone here been raped and speak English?"
ReplyDeleteWell worth reading, that, if you can track down a copy. If only for the anecdote about Winston Churchill.
ReplyDeletePhil,
ReplyDeleteGod yes. When I had surgical emphysema [probably because someone punctured my trachea during an op] they couldn't stay away. Little queues of medical students and surgeons to have a poke.
"We don't see this much anymore"
"Oh, isn't it like bubble wrap"
"Mary, come and have a poke"