The Arizona Skeptic online: vol. 6, 1992-1993

Continuing the postings of The Arizona Skeptic; you can find volume 1 (1987-1988) here, volume 2 (1988-1989) here, volume 3 (1989-1990) is here, volume 4 (1990-1991) is here, and volume 5 (1991-1992) is here. Volume 6 was edited by Jim Lippard and has been available online since original publication as ASCII text. An index to all issues by title, author, and subject may be found here. The Arizona Skeptic, vol. 6, no. 1, July/August 1992 (text version):

• "Science and Dianetics" by Jeff Jacobsen
• "A Healthy Dose of Sarsaparilla" by Jerome L. Cosyn
• "Book Review: Combatting Cult Mind Control by Steven Hassan" reviewed by Chaz Bufe
• "Michael Persinger and Tectonic Strain Theory" by Jim Lippard
• "Rutkowski's Work" and "Other Critical Works" (bibliography of papers critical of TST assembled by Chris Rutkowski)
• "Book Review: Logic and Contemporary Rhetoric by Howard Kahane" reviewed by Jim Lippard
• "Book Review: Sai Baba's Miracles by Dale Beyerstein" reviewed by Jim Lippard
• Media Update
• Newsletter Production Volunteers Needed
• Electronic Version of the Newsletter
• Upcoming Meetings: September speaker Chaz Bufe on Alcoholics Anonymous
• Articles of Note

The Arizona Skeptic, vol. 6, no. 2, September/October 1992 (text version):

• "How Much of Your Brain Do You Use?" by Mickey Rowe
• "Phoenix Skeptics and the Sedona Harmonic Diversion" by Mike Johnson
• "Jehovah's Witnesses and Earthquake Frequency" by John Rand (pseudonym for Alan Feuerbacher)
• "The Institute for Creation Research and Earthquake Frequency" by Jim Lippard
• "QUAKE DAY - Minus 7" by Mike Jittlov
• "New Skeptical Group/Magazine" (Skeptics Society/Skeptic magazine)
• Upcoming Meetings: October speaker Peter Lima on the search for the historical Jesus
• Articles of Note

The Arizona Skeptic, vol. 6, no. 3, November/December 1992 (text version):

• "Report on the 1992 CSICOP Conference: Part One" by Jim Lippard
• "A Visit to Dinosaur Valley State Park" by Richard A. Crowe
• "The End of Crop Circles?" by Chris Rutkowski
• Next Issue
• Upcoming Meetings
• Articles of Note

The Arizona Skeptic, vol. 6, no. 4, January/February 1993 (text version):

• "Predictions for 1993"
• "Jeane Dixon Predicts Bush Victory"
• "Report on the 1992 CSICOP Conference: Part Two" by Jim Lippard
• "Book Review: Impure Science: Fraud, Compromise and Political Influence in Scientific Research by Robert Bell" reviewed by Jim Lippard
• "Book Review: Taking Time for Me: How Caregivers Can Effectively Deal with Stress by Katherine L. Karr" reviewed by Michael A. Stackpole
• Upcoming Meetings
• Reader Survey
• Articles of Note
• Magazine/Journal Subscription Information

The Arizona Skeptic, vol. 6, no. 5, March/April 1993 (text version):

• "CSICOP Questions Truth of Movie Based on Travis Walton UFO Abduction"
• "MIS-Fire in the Sky" by Chris Rutkowski
• "Linda Napolitano UFO Abduction Case Criticized" by Jim Lippard
• "Book Review: The Retreat to Commitment by William Warren Bartley III" reviewed by David A. Snodgrass
• "Camille Paglia: Astrologer"
• Skeptical News
• Upcoming Meetings
• Books of Note
• Articles of Note

Volume 6 concluded my editorship, and volume 7 returned for one more issue edited by Mike Stackpole.

Science-based medicine conference, part 3: chiropractic

This is part three of my summary of the Science-Based Medicine conference at TAM7, which will be followed by a summary of TAM7 itself. Part one, Dr. Steven Novella's introduction, is here. Part two, Dr. David Gorski on cancer quackery, is here.

The next session was Dr. Harriet A. Hall, the "SkepDoc," a retired family physician and former Air Force flight surgeon, on "A Scientific Critique of Chiropractic."

Chiropractic
Dr. Hall began her talk by observing that 10% of Americans see a chiropractor some time each year, and said that her talk would address the questions of when you should see a chiropractor, what they really do, is it based on science, and why isn't it part of regular medicine.

Chiropractic, she said, is a pre-scientific system that was discovered on a single day (September 18, 1895) by D. D. Palmer, a grocer and magnetic healer. On that day, he performed a spinal manipulation on a deaf janitor and allegedly cured his hearing, and based on that single case, claimed that he had found the cause of all disease. Hall noted that in 1895, Pasteur had just died, X-rays had just been discovered, and the germ theory of disease was just catching on. For perspective, she noted that 1900 was the first year in which you would have a 50% chance of having a beneficial outcome from a visit to a doctor.

Chiropractic theory says that all disease is caused by subluxations, or dislocated joints, causing nerve impairment, thereby impacting the flow of "Innate," a mystical force that flows through us. There are real subluxations, which are visible on X-rays, but chiropractic subluxations have never been demonstrated to exist. The chiropractic finding of "Boop"--bone out-of-place--can't be documented on X-rays, and chiropractors have claimed that they are as small as 1/10,000,000 mm.

The current chiropractic definition of subluxation (as defined by the American Association of Chiropractic Colleges) has been adjusted to be more vague: "a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system and general health."

Palmer said that 95% of ill health and disease is caused by spinal subluxations, and 5% from misalignments of other bones. Hall suggested that if this were true, invertebrates wouldn't get sick, though perhaps chiropractors would say that Palmer was only speaking of the causes in humans. She went on to point out that a ruptured disc is an example of a spinal injury which causes pain without subluxation, directly refuting Palmer's claim.

The chiropractic theory of nerve impingement often uses a garden hose analogy, that a kink in the hose causes water to back up on one side of the kink. But this analogy is not correct, because nerve conduction speed is only affected at the point of compression, as seen in carpal tunnel syndrome. While such nerve dysfunctions do exist, they don't work the way chiropractic says, and they are not the cause of most disease.

A further problem for chiropractic is that 12 cranial nerves and 5 sacral nerves are out of reach for chiropractic manipulation.

Hall showed a diagram about the flow of "Innate" which showed the doctor's "Innate" influencing the patient's "Innate," but for which there was no described mechanism. There is, of course, no evidence that "Innate" exists, and it's now rejected by many chiropractors.

The audible crack from chiropractic manipulation, Hall said, is just like knuckle cracking, and has no therapeutic effect except perhaps for its psychological impact. She noted that at least one chiropractor cracks her own wrists and doesn't actually touch her patients!

Osteopathy and Chiropractic
Hall compared osteopathy to chiropractic with this chart:

Osteopathy	Chiropractic
restoring blood flow minimize spinal manipulation therapy (SMT) adopted science	restoring nerve flow maximize SMT nope

Spinal manipulation therapy, said Hall, works as well as other treatments in treating back pain, and there is no evidence that it assists in treating anything other than back pain. A problem in testing SMT is that good placebo controls are impossible, because the patient can tell when SMT is occurring or not. Single blinding is impossible, let alone double blinding. There are also many variations of technique possible.

Tooth Fairy Science
Dr. Hall argued that chiropractic study is something like what she called "tooth fairy science." You could perform tests of the tooth fairy, by putting lost teeth into baggies vs. facial tissue before putting it under the pillow, comparing the amount of money received for the first lost tooth to the last lost tooth, looking for correlations with parental income, and so forth, but none of this would tell you anything about an entity called the Tooth Fairy.

She gave an anecdote of a man suffering from back pain who made an appointment with a chiropractor for the following Monday. Over the weekend, his pain went away--if he had made his appointment for Friday, he would have attributed the pain going away to the chiropractic treatment and perhaps ended up as a believer and regular patient.

She compared this to the "blue dot cure," a treatment by painting a blue dot on your nose (any nonsensical treatment suffices for the illustration). If the patient gets better, that's evidence that it worked. If the patient stays the same, that's evidence that the treatment kept him from getting worse. And if the patient gets worse, that's evidence that the disease was too far advanced, and if only he had come sooner it would have been treatable. (Or, alternatively, it's evidence that more treatment is required--say, upping the dosage of the remedy or painting a darker blue spot on the patient's nose.)

What chiropractors do well, Hall said, is help with back pain and act as good psychologists. But they've gotten thumbs down the New England Journal of Medicine, Consumer Reports, The Medical Newsletter, Canadian neurologists, and many other sources, not just because of claims to be able to treat things that it can't treat, but because of safety issues.

The Big Downside of Chiropractic
Chiropractic manipulation of the head and neck turns out to be dangerous. It can compress or tear vertebral arteries, resulting in strokes, perhaps as frequently as in one in a million manipulations, and perhaps 20% of basilar strokes are caused by spinal manipulations. Hall pointed out that mobilization is as effective as manipulation, yet is safe--so there's no reason to use the riskier method.

The Canadian neurologists mentioned above have recommended that signs warning signs be posted in chiropractic offices and that neck manipulation of children be prohibited.

Insurance data on payouts for chiropractic malpractice show that about 9% of payouts in 2002 were for "CVA," or cerebrovascular accident.

The numbers are likely under-reported, since there may be some time between a manipulation that causes damage and a stroke.

Chiropractors as Quack Magnets
A further problem with chiropractic is that practitioners are "quack magnets," promoting all sorts of bogus diagnostic methods and treatments such as moire contour analysis, use of a "neuroscope" that measures temperature differences and pressure, biofeedback as a form of electrodermal testing, applied kinesiology (pseudoscientific muscle strength testing), unnecessary dietary supplements, homeopathy, and reflexology. Hall also mentioned B.J. Palmer's (D.D. Palmer's son) "Atlas Adjustment" technique, or "hole in one" technique, which suggests that manipulation of the Atlas vertebra is sufficient to cause the rest of the spine to fall into alignment.

Chiropractors also tend to overuse X-rays, such as taking full-spine X-rays which expose the reproductive organs and inevitably produce overexposed or underexposed areas. Proper X-raying focuses on smaller areas to get the right exposure.

Chiropractors offer bad advice, frequently discourage immunizations and other medical treatments, and they frequently miss diagnoses of real illnesses. In one test of chiropractors, patients were sent in to describe classic heart attack symptoms, but none of the chiropractors in the test recognized it or its significance, and none suggested that the patient visit an emergency room.

Types of Chiropractor
There are three major chiropractic groups. The International Chiropractors Association (ICA), or "straights," who practice only chiropractic. The American Chiropractic Association (ACA), or "mixers," who mix chiropractic with other diagnostic and treatment techniques. And the National Association for Chiropractic Medicine (NACM), who are attempting to reform chiropractic by disassociating it from Palmer's pseudoscience and using only evidence-based scientific medicine.

Chiropractic Thinking and Hallmarks of Pseudoscience
Hall gave some examples of chiropractic thinking that is blatantly wrong or harmful:

• If spine is straight, we can't die.
• Germs don't cause disease, or we'd all be dead.
• Muscle testing to find allergies. (In one case, a patient was tested for job-related stress with applied kinesiology, by pushing down on his arm while he thought of work.)
• Spinal adjustments as the only treatment for meningitis, resulting in the child's death--and it was the chiropractor's own child.
• A "no-touch" chiropractor (cracking own wrists, mentioned above).

And examples of how chiropractic exhibits the hallmarks of pseudoscience:

• "If science disproved it, I'd still use it."
• It doesn't give up ineffective treatments.
• It's made no progress over the last century.
• It doesn't matter whether it's true as long as it makes you feel better.

Dr. Hall concluded her talk by giving several three examples of concrete harm from chiropractic taken from Tim Farley's "What's the Harm" website, which lists 312 specific cases of chiropractic harm:

Kristi Bedenbaugh: Suffered a stroke and died.
Sandra Nette: Suffered multiple strokes and was left paralyzed with locked-in syndrome.
Laurie Jean Mathiason: Fell into a coma and died after receiving 186 neck manipulations in a six-month period.

Dr. Hall recommended the Quackwatch site and Chirobase.org as online resources on chiropractic, and the book Inside Chiropractic by chiropractor Samuel Homola and Quackwatch founder Stephen Barrett.

Q&A
In the Q&A session, Dr. Hall was asked whether chiropractors are required to follow a standard of care and whether informed consent is required. She said that informed consent is not required, it is voluntary, and the informed consent forms that she's seen are very bad. She was also asked how many chiropractors meet the good and safe criteria, and she made a guess of under 10%.

(Part four of my conference summary, on evidence-based medicine and homeopathy, is here. Part five, on chronic Lyme disease, is here. Part six, on online health and social media, and the closing Q&A panel, is here.)

Science-based medicine conference, part 2: cancer quackery

This is part two of my summary of the Science-Based Medicine conference at TAM7, which will be followed by a summary of TAM7 itself. Part one is here.

David Gorski, surgical oncologist and associate professor of surgery at Wayne State University, perhaps better known as Orac of the Respectful Insolence blog, spoke next on "Case studies in cancer quackery: Testimonials, anecdotes, and pseudoscience." He began with a disclaimer (he doesn't speak for his employer) and some disclosures (he receives no pharma funding and isn't paid to blog).

His talk was about misrepresentations by cancer quacks, who use exaggeration and misrepresentation and make false promises. To illustrate exaggeration, he showed a cartoon that described "three approved paths to the graveyard," "cut" (surgery), "burn" (radiation), and "poison" (chemotherapy) (the exaggeration is in the title rather than the descriptions, which are he admitted were accurate). To illustrate the latter, he showed a series of book covers by Hulda Clark--"The Cure for All Advanced Cancers," then "The Cure for All Cancers," and then "The Cure for All Diseases." She thinks that all cancers and diseases are caused by liver flukes, to be diagnosed with a "Syncrometer," a device similar to a Scientology E-meter, a galvanometer that measures electrical resistance of the skin, and cured with the "Zapper," a low voltage electrical device.

Some of the frequent claims of cancer quacks are that they are "wholistic" and treat the whole patient rather than a part or a symptom, that "we treat the real cause of cancer," that their treatment is "natural," and that "cancer is not the disease, it's a manifestation of something else" such as psychological conflict. And, of course, the ever-popular generic "toxins." They also claim that natural cures are being suppressed because Big Pharma can't make a profit from them.

Testimonials
Gorski next turned to the role of testimonials in cancer quackery, which he said are being used for several reasons, the first N of which are "to sell a product." Two other reasons are "to persuade others" and "to attack standard evidence."

He gave Gorski's Laws of Testimonials:

1st Law: When a believer in Alternative-Based Medicine (ABM) uses a combination of both science-based medicine (SBM) and ABM and gets better, it's always the ABM that gets the credit.

2nd Law: When a believer in ABM uses a combination of both SBM and ABM and dies or gets worse, it's always SBM that gets the blame.

He next described two cases of testimonials, the first of which was an example of a "not cancer" testimonial. This was a testimony of a man who felt a lump on his chest which he claimed to be breast cancer, which was successfully treated by some quack remedy. But this was never diagnosed as cancer, and Gorski noted that from the description it actually sounded like a case of gynecomastia rather than cancer. His second case was that of Daniel Hauser, a 13-year-old boy with Hodgkin's lymphoma, who went through one round of chemotherapy with good results, but then stopped taking it because he and his mother wanted to use an alternative treatment from "Chief Cloudpiler." The judge ordered chemotherapy to be continued, and he and his mom took off, though ultimately returned and re-started chemotherapy. During the time chemotherapy stopped, the tumor grew to larger than it was originally, and when it was restarted, it again responded to treatment--but of course his mother gave credit to the alternative treatment.

The problems with testimonials are that there may not have been a diagnosis of cancer, there may have been a misunderstanding of the diagnosis (e.g., "I was sent home to die"), there may be important information withheld, the diagnosis may have been done by quack tests with no validity (e.g., the Syncrometer or live blood cell analysis), and there may be a selection bias. As an example of the latter, he noted that dead people don't give testimonials.

Questions for Evaluating Testimonials
He provided a modified version of Dr. Moran's questions to ask in order to evaluate testimonial evidence. These questions include:

• Was cancer definitely present?
• Did it go away?
• Was the advocated treatment the only one used?
• Was the alternative therapy a replacement for primary or for adjuvant therapy?

At this point, he distinguished primary, adjuvant, and neo-adjuvant therapies. The primary therapy for most cancer treatments is surgery, to remove as much of it as possible. Adjuvant therapy is designed to reduce the risk of recurrence, where radiation is used to reduce the risk of local recurrence (cancer in the same place, to make sure you get rid of it all) and chemotherapy is used to reduce the risk of a systemic recurrence (cancer that may have spread to other parts of the body). Neo-adjuvant therapy is designed to shrink a tumor prior to surgery, and may reduce complications and produce better results from surgery.

Suzanne Somers
To illustrate the importance of these questions and distinctions, he used the case of Suzanne Somers, who was diagnosed with breast cancer at the age of 54, probably at stage I. She had no positive lymph nodes and underwent a lumpectomy, radiation, and a lymph node biopsy, but refused chemotherapy with tamoxifen in favor of mistletoe extract and other supplements.

In her case, the answers to the questions were:

• Was cancer present? Yes.
• Did it go away? Yes--it was removed by surgery.
• Was the alternative medicine the only or primary treatment? No.

He then examined her probable survival rates with and without chemotherapy, and noted that if the tumor was small, the benefit of chemotherapy for her 10-year survival rate could be as low as 1%. With a larger tumor, her 10-year survival rate improvement could still be as low as 4% (and would already be at 90% prior to chemo). But, Gorski noted, most women say that they would go with chemotherapy even for as little as a 1% increase in survival rate.

Surgery cures most cancers that can be cured, up to stage III, and the corresponding benefits of chemo and hormonal therapy increase with more advanced stages of cancer.

Gorski then observed that there may be cases where a person is diagnosed with cancer by a biopsy, declines further treatment, and has a good survival rate, where they fail to realize that the biopsy itself has been a surgical primary treatment that has excised all of the cancer--an excisional biopsy may be equivalent to a lumpectomy. He also noted that many people say to go ahead and take out the tumor but don't touch my lymph nodes, and he agreed that lymphedema, which can be caused by surgical or radiation treatment of the lymph nodes, is "not a fun thing." But the new standard of care is to use blue dye and a radiotracer procedure to find lymph nodes likely to be positive for cancer ("sentinel lymph nodes"), and treat accordingly.

Kim Tinkham
Kim Tinkham is a woman who saw The Secret, had stage III breast cancer, and declined all treatment. She now claims the cancer is gone, based on a quack blood test, even though the lump is still present, and has written a book about it. She is a follower of Mormon naturopath Robert O. Young, who claims that acid is the cause of all disease and alkalinization is the cure for everything. He says there is no such thing as a cancer cell, just a healthy cell spoiled by acid. Two years after her initial diagnosis, Tinkham is still alive.

Gorski pointed out that for a case like hers, expected survival for five years with treatment could be over 50%, but at ten years it goes way down. Data about untreated cancer comes from 250 cases of "large palpable tumors" from 1805-1933 at Middlesex Hospital in Connecticut. At 10 years, 3% were still alive, and at 15 years, 0.8% were still alive; the median survival rate was 2.87 years.

He noted that breast cancer biology is "highly variable in clinical behavior" and in some cases may be "indolent, slow-growing, and slow to metastasize."

The answers to the testimonial questions for Tinkham are:

• Was cancer definitely present? Yes.
• Did it go away? No.
• Was the alternative treatment the only one? Yes.

Time will no doubt soon tell how (in)effective this alternative treatment has been, unfortunately.

Testimonials as Conversion Stories
Gorski suggested that these testimonies are really part of "cult medicine" and seem to follow a pattern like religious conversion stories. The specter of death comes like a "bolt out of the blue," the person repents and says "I brought this upon myself," they face temptation in the form of standard medical care, they search for enlightenment, and then they find enlightenment in the form of some alternate description of their ailment which they then want to evangelize.

Michaela Jakubczyk-Eckert
Dr. Gorski concluded his talk with the story of Michaela Jakubczyk-Eckert (warning, graphic images), who was born on November 14, 1964 and died on November 12, 2005, just two days short of her 41st birthday. She had a T4 lesion eating through the skin of her breast, a case of "classic delayed diagnosis." She received neo-adjuvant chemotherapy treatment which shrank the tumor considerably, but then discovered Ryke Geerd Hamer, the inventor of German New Medicine, who argued that cancer is caused by psychological conflict rather than anything biological. She stopped her chemotherapy, and suffered a horrible relapse. As Gorski put it, she "died a horrible, horrible death" with her final days being subjected to the pain of a rotting-away body of skin and bones--a death far worse than chemotherapy. It was a vivid depiction of the alternative that cancer quacks can cause for their victims. Her husband has put up a website to try to dissuade others from being fooled by Hamer's theories (see link above to her story).

Dr. Gorski has written a blog post at the Science-Based Medicine blog on alternative medicine testimonials that covers some of the above subjects in more detail.

(Part three of my conference summary, on chiropractic, is here. Part four, on evidence-based medicine and homeopathy, is here. Part five, on chronic Lyme disease, is here. Part six, on online health and social media, and the closing Q&A panel, is here.)

Science-based medicine conference, part 1

This year's "The Amazing Meeting" (TAM7) was preceded by a Science-Based Medicine conference, organized by Steven Novella and the Science-Based Medicine blog; the speakers were all contributors to that blog. This summary is from my hand-written notes--I've tried to quote and summarize accurately, but keep in mind that some of the quotations and bulleted items may not be verbatim. The conference was videotaped and may become available via DVD or online video; keep an eye on the SBM blog for that. Steven Novella has posted a short summary of the SBM conference at the SBM blog.

I am in the process of posting a summary of TAM7 itself, which begins here. (I summarized 2008's TAM6 here.)

Novella's Introduction
The SBM conference began with Novella's presentation, titled "Science-Based Medicine: Science and Pseudoscience in Clinical Decision Making," which distinguished science-based medicine (SBM) from the recently popular "evidence-based medicine" (EBM) and explained the motivation for promoting the SBM concept.

Novella, assistant professor of clinical neurology at Yale University School of Medicine, began with a slide titled "Foundations of Medicine" which described some historical varieties of medicine:

• Superstition/philosophy-based medicine.
• Scientific medicine.
• Evidence-based medicine (EBM).
• Eastern vs. Western medicine.
• Complementary and alternative medicine (CAM).

He made the point that modern scientific medicine, which arose in the western world, is relatively young, though attempts to put it on a more scientific footing go back much farther.

Next, he discussed "What is science," first observing that "scientifically formulated" is a meaningless marketing label, then noting that there is a battle of memes about science between its defenders, who use it as a label connoting "objective truth, quality, and professionalism," and its critics, who use it as a label connoting "arrogance, oppression, and elitism." Marketers also use it "to imply product safety, effectiveness, and overall value."

He argued that we should adopt "common sense standards" which require that treatments "reasonably account for all available evidence," use "valid and internally consistent logic," have been rigorously and methodically investigated and judged with fair and unbiased criteria, and are conducted by practitioners who adhere to "standards of ethics and professionalism."

Evidence-Based Medicine
Next, he looked at evidence-based medicine, a term of art in use for the past couple of decades. EBM begins with the premise that "products and practices that work and are safe are better than those that don't work or are unsafe," an uncontroversial premise. It promotes scientific investigation as the measure of what works and is safe. But, according to Novella (and later, other speakers), EBM has "too much focus on evidence, and not enough on logic and prior probability, and good science must consider both." He argued that EBM made sense at the time it was introduced, because practices were being used largely "because they made sense, not because of supporting evidence." The introduction of EBM effectively "leveled the playing field, but also opened it up to implausible treatments," with bad timing due to the rise of complementary and alternative medicine (CAM).

The standard reference for evidence in the EBM framework is the Cochrane Reviews. The data reported in the Cochrane Reviews includes not only tests of legitimate medical treatments, but of completely implausible research such as chiropractic treatment for migraine. The problem with the framework is that it assumes that everyone is "playing fair," it does not account sufficiently for fraud or publication bias (such as the "file drawer effect"), it ignores prior probability, and it "doesn't adequately consider the big picture of the entire literature." According to Novella, with EBM it is typical to see the quality of studies decline over time, in order to continue to yield positive results for implausible treatments.

He then discussed "The Work of John Ioannidis," who argues that "most published research findings are false." The reasons are that

• The majority of highly-cited initial medical research is later refuted.
• There's a bias towards publishing positive studies.
• There's a bias towards researchers publishing provocative research.
  

And a "low prior probability worsens the effect," i.e., studies of treatments with low prior probability are more likely to be refuted.

Science-Based Medicine
By contrast with EBM, Novella identified the following features to distinguish Science-Based Medicine, SBM:

• It affirms high-quality science as a basis for standard of care in medicine.
• It acknowledges the consilience of science.
• It considered scientific medical plausibility of an intervention when weighing evidence.
• It considers the overall pattern in the literature.

In other words, SBM considers prior probability in a Bayesian sense as part of the evaluation, it looks at whether there is other scientific evidence that casts doubt on the plausibility of a suggested treatment (like violating the laws of physics or including unknown entities and mechanisms), in addition to merely looking at the specific results of controlled trials of the particular treatment. CAM, in particular, is loaded with claims that have extremely low and near-zero prior plausibility, as evidenced by the fact that $1.2 billion of U.S. taxpayer funding to the National Center for Complementary and Alternative Medicine since its founding in 1991 (originally as the Office of Alternative Medicine) has so far yielded zero effective treatments for anything.

He stated that finding anomalies argues for deeper research, and we can't have two inconsistent views that both work. Here, I think he overstated his case, since we have had cases in science where there are mutually inconsistent theories that both work, though we also take the inconsistency as grounds that something is wrong and ultimately needs to be reconciled (e.g., light wave/particle duality, quantum field theory vs. general relativity). Even theories that are wrong at some level can still work for solving certain kinds of problems (e.g., Newtonian physics)--and I'd agree with Novella's claim that scientific medicine is still in its infancy. A point Novella didn't make that I would like to insert here is that when you have two inconsistent views that doesn't mean that only one of them must be wrong--they could both be wrong.

Novella did go on to mention two cases where things that seemed initially implausible or lacking in mechanism have turned out to be correct, the postulation of dark energy in physics, and, more directly relevant to the topic at hand, the use of botulinum as a treatment for migraine. This treatment seemed to him completely implausible even though the evidence of trials suggested its effectiveness, and now a mechanism has been discovered and is understood. (My Google searching on this subject, however, yielded some recent evidence that it is not a good treatment for migraines and is no better than placebo, so this appears to me to still be somewhat controversial.)

Clinical Decision-Making
Novella ended his talk by talking about the process of clinical decision-making and pitfalls that arise as a result of human psychology and limitations. While clinical decision-making "individualizes the best available evidence to a specific patient" and "considers risk vs. benefit in both therapeutic and diagnostic intervention," this evaluation needs to include not acting as an alternative. In some cases, screening for certain diseases causes more harm than not performing the screening test, because conducting the test will yield far more false positives than true positives. (This is an effect discussed in some detail in John Allen Poulos' book, Innumeracy, and is a reason not to do things like mandatory HIV screening as a condition of a marriage license, drug testing of grade school students, and certain kinds of security screening for terrorists--if your baseline prevalence of what you're testing for is very low, your false positive results will swamp your true positive results.)

He briefly discussed the claim that "surgery kills more people than car accidents," noting that it doesn't really compare against the outcomes that would occur without surgery--far more deaths.

He then recounted some examples of pitfalls in the clinical context, such as the human capacity for pattern recognition even when the pattern isn't really there (pareidolia), the tendency to be "unduly influenced by quirky experience" or to "value experience over evidence," "failure to consider alternatives," "over-reliance on non-specific signs and symptoms," and confirmation bias (e.g., the sorts of heuristics and biases discussed in Kahneman and Tversky's classic Judgment Under Uncertainty). He then listed a few logical fallacies, pointed out the confounding factor of the placebo effect, and a couple of statistical effects--regression to the mean and the fact that most diseases are self-limiting.

Q&A
In the Q&A session, someone asked what Novella thought of legislation supporting evidence-based medicine, apparently referring to $1.1 billion in the stimulus package for evidence-based medicine research. Novella said that he thought conceptually it was a good idea but wasn't familiar with the specifics of the legislation. Another question was whether, given the current state of health care and the desire for reform, SBM would be challenged or supported. Novella said that the delivery of healthcare is a separate issue from how we decide what to research or what treatments are appropriate, and that things will either get much better or much worse. If he had also added that things might also stay about the same in overall quality, I'd say he's certainly correct; without it, merely probably correct.

(Part two of my conference summary, on cancer quackery, is here. Part three, on chiropractic, is here. Part four, on evidence-based medicine and homeopathy, is here. Part five, on chronic Lyme disease, is here. Part six, on online health and social media, and the closing Q&A panel, is here.)