Month: April 2012

What is “Unnecessary” Medicine?

Seth Roberts1 Comment

An organization called the American Board of Internal Medicine Foundation has launched a campaign to reduce the cost of health care by reducing “unnecessary” tests, drugs, and procedures. A bare-bones website lists them. For example:

Don’t routinely do diagnostic testing in patients with chronic urticaria [hives].

Here is the explanation of that recommendation:

In the overwhelming majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory testing may be warranted to exclude underlying causes. Targeted laboratory testing based on clinical suspicion is appropriate. Routine extensive testing is neither cost effective nor associated with improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated, unless there is a clear history implicating an allergen as a provoking or perpetuating factor for urticaria.

Not clear. Are they trying to say the tests are useless (“not associated with improved clinical outcomes”)?

My broad question about the campaign is: What does “unnecessary” mean? This is not explained on the website nor in a Washington Post article about the campaign.

A nearby article on the Post website is about “the downside of mammography”. It says:

A study published Monday in the Annals of Internal Medicine adds to a growing body of evidence that the potential risks of routine breast-cancer screening via mammography might in fact outweigh such screening’s benefits.

That’s clearer. It seems to be saying the costs outweigh the benefits. (What are “potential” risks? I thought all risks were potential.) But that doesn’t mean that breast cancer screening is “unnecessary”, it means it is a bad idea.

If the foundation is trying to say that a lot of medicine does more harm than good, then, please, say so. If they are trying to say that a lot of medicine is useless, then, please, say so. Stop being polite.

I contacted the foundation to ask them about this.

Thanks to Bryan Castañeda.

Lack of Repeatability of Cancer Research: The Mystery

Seth Roberts14 Comments

In a recent editorial in Nature (gated), the research head of a drug company complained that scientists working for him could not repeat almost all of the “landmark” findings in cancer research that they tried to repeat. They wanted to use these findings as a basis for new drugs. An article in Reuters summarized it like this:

During a decade as head of global cancer research at Amgen, C. Glenn Begley identified 53 “landmark” publications — papers in top journals, from reputable labs — for his team to reproduce. Begley sought to double-check the findings before trying to build on them for drug development. Result: 47 of the 53 could not be replicated.

Yet these findings were cited, on average, about 200 times. The editorial goes on to make reasonable suggestions for improvement based on differences between the findings that could be repeated and those that could not. The Reuters article goes on to describe other examples of lack of reproducibility and includes a story about why this is happening:

Part way through his project to reproduce promising studies, Begley met for breakfast at a cancer conference with the lead scientist of one of the problematic studies. “We went through the paper line by line, figure by figure,” said Begley. “I explained that we re-did their experiment 50 times and never got their result. He said they’d done it six times and got this result once, but put it in the paper because it made the best story.

Okay, cancer research is less trustworthy than someone just barely outside it (Begley) ever guessed. Apparently careerism is one reason why. What is unexplained in both the Nature editorial and the Reuters summary is how research can ever succeed if things aren’t reproducible. Science has been compared to a game of Twenty Questions. Suppose you play Twenty Questions and 25% of the answers are wrong. It’s hopeless. In experimental research, you generally build on previous experimental results. The editorial points out that the non-reproducible results had been cited 200 times but what about how often they had been reproduced in other labs? The editorial says nothing about this.

I can think of several possibilities: (a) Current lab research is based on experimental findings of thirty years ago when (for unknown reasons) careerism was less of a problem. Standards were higher, there was less pressure to publish, whatever. (b) There is a silent invisible “survival of the reproducible”: Findings that can be reproduced live on because people do lab work based on them. The other findings are cited but are not the basis of new work. (c) There is lots of redundancy — different people approach the same question in different ways. Although each individual answer is not very trustworthy their average is considerably more trustworthy.

Leaving aside the mystery (how can science make any progress if so many results are not reproducible?), the lack of reproducibility interests me because it suggests that the pressure to publish faced by professional scientists has serious (bad) consequences. In contrast, personal scientists are under zero pressure to publish.

Thanks to Bryan Castañeda.

Assorted Links

Seth Roberts2 Comments
  • Where are they now? J. S. Boggs, profiled by Lawrence Wechsler in The New Yorker. Boggs made small paintings closely resembling money (e.g., a $100 bill) that he offered in place of real money. He sold surrounding details (e.g., the receipt) to a collector who would try to get the bill Boggs had drawn from the merchant in order to “complete” the work of art.
  • A SLDer (Shangri-La Dieter) loses 80 pounds in 18 months. That’s 1.0 pounds/week.
  • More medicine does not equal better medicine. I agree with every word of this critique by a Glasgow general practitioner named Des Spence. For example, “The prescribing of powerful antipsychotic and potentially addictive stimulant drugs to children is a societal norm. . . . A quarter of US women are taking mental health drugs.” As Spence says, these are signs of a healthcare system biased toward those who make money from it and against everyone else (including children). One way to sum up why this is a mistake: Your health is too important to be left to those who only make money if you are sick.
  • Japan: from rice to wheat to rice.

Thanks to Bryan Castañeda.

Moderate Alcohol Consumption Associated With Less Cirrhosis

Seth Roberts10 Comments

Alcohol is bad for your liver, we’re told. However, moderate amounts may be good for your liver. A recent meta-analysis found that men who drank moderate amounts of alcohol had considerably less risk (a risk ratio of 0.3) of liver cirrhosis than men who drank no alcohol. It wasn’t clear if some forms of alcohol (e.g., wine) were more protective than others. I came across this study because another article called the association “biologically implausible”, whereas I think it is highly plausible due to vast experimental literature on hormesis (animals given small amounts of poisons are healthier than animals given none).

The findings about cirrhosis join a much large body of evidence that moderate drinking is associated with less heart disease. A recent meta-analysis reached this conclusion once again and found, in addition, that moderate drinking is associated with less all-cause mortality.

These are more examples of the health benefits of fermented foods, one of my favorite subjects. It is unfortunate the liquor industry does not run long-term human experiments on the effects of moderate amounts of beer, wine, and so on.