Angry Doctor

Tuesday, April 01, 2008

Science and how we know we are right 2

Mr Wang comments on the issue of aesthetic 'medicine' in his post today, and once again angry doc finds himself disagreeing with his take on science.

Specifically, angry doc takes issue with the following passages:


"I am quite confident that most, if not all, the aesthetic treatments offered by your neighbourhood HDB beautician are also "scientifically unsubstantiated". This does not mean that all these aesthetic treatments do not work.

It merely means that the treatment either does not work, or the treatment works, but has not been "scientifically" proven to work. And most of the time, the latter simply means that scientists have not bothered to do research on that particular treatment."


It is quite common to see supporters of unproven therapy argue for their pet therapy this way, but in reality those passages actually contain a few separate flawed arguments.

First of all, by saying that an unproven therapy may actually work but "scientists have not bothered to do research on that particular treatment", one is trying to shift the burden of proof from those who propose and support such treatment. The logical way is of course to require those who propose and support the claims of such treatment to offer evidence for its efficacy, and not the other way round - otherwise anyone can make unfounded claims and there will not be enough scientists to go around debunking these claims. The legal equivalent would be to put the onus on the defence to prove the innocence of the accused, instead of requiring the prosecution to prove its case of guilt.

Also, for some forms of unproven therapy there is not only an absence of evidence of efficacy, but there is in fact evidence of a lack of efficacy. angry doc is unable to find any study on the efficacy of facials (OK, he didn't bother to look), but a quick search on "mesotherapy" on PubMed revealed more articles on the complications of that mode of therapy than articles on efficacy, and the latter do not support the claims of efficacy in body contouring.

Of course, it is true that scientists "have not bothered to do research" on certain modes on unproven therapy. The burden of proof aside, this is also due to consideration on the prior probability of a claim, or the lack of any plausible physiological or known physical mechanism by which these therapy claim to work. If angry doc claimed that he could shoot invisible bolts of energy from his hands to calm your pet cat, he would not be surprised that scientists will not bother to research his claims; that doesn't mean his claim is true, it just means that scientists may have more important things to do, like finding a cure for AIDS or cancers.

Labels:

posted by angry doc at 5:30 pm

42 Comments:

  • ".... by saying that an unproven therapy may actually work but "scientists have not bothered to do research on that particular treatment", one is trying to shift the burden of proof from those who propose and support such treatment. The logical way is of course to require those who propose and support the claims of such treatment to offer evidence for its efficacy, and not the other way round ...."

    What you may like to think about is -

    who is putting the burden of proof on who to prove efficacy,

    and why is the burden of proof being placed where it is being placed?

    For example, suppose I am of the view that:

    1. consuming ginseng regularly is good for my health; and

    2. a weekly shiatsu-style massage is very beneficial for reducing my stress levels.

    No doubt my views are scientifically unsubstantiated. I don't believe that many scientists would have done studies on ginseng or on the effect of shiatsu-style massage on stress.

    But who ....

    (you? the public? the Ministry of Health? the Academy of Medicine?)

    is placing the burden of proof on who ....

    (Me? The Chinese medicine shop man? The masseue? Ginseng farmers? Spa customers?)

    to prove the efficacy of ginseng / shiatsu massage? And why should the burdenee feel obliged to offer proof to the burdener? Especially proof in a form - scientific proof - which is really quite inconvenient for anyone, except scientists with sufficient research funding & sample sizes, to produce?

    And in the meantime, are you saying that ginseng shouldn't be cultivated and shiatsu massage shouldn't be done?

    By Blogger Gilbert Koh aka Mr Wang, At April 01, 2008 10:41 pm  

  • You got me there, Mr Wang.

    Yes, me and Big Science are setting up arbitrary rules and impossible-to-attain standards to oppress small operators so they can't have the freedom to hold views contrary to ours. Our ultimate aim is to ban ginseng cultivation and shiatsu massage.

    OK, with sarcasm out of the way, let's look at how your argument attempts to mislead readers and confuse the issues here.

    1. You begin by citing a couple of "views" you might hold. These are rather innocuous view, being as they are views that ginseng is "good for my health" and massage is "beneficial for reducing my stress levels".

    The first is too vague to discuss (what exactly constitutes "good for my health"?), and the second being a largely subjective feeling (although if we chose to define "stress levels" we can actually test that view).

    2. You then go on to ask why you should be made to prove the efficacy of ginseng/shiatsu massage.

    Well, a view remains a view as long as it is what you choose to believe, but once you want to make a claim of efficacy, it is no longer simply a "view".

    Anyone can of course hold any view he or she desires, but once it becomes a 'claim', and when someone tries to convince other people of claims of efficacy, proof becomes relevant, don't you think?

    As for who has the right to ask for burden of proof, I would say anyone to whom the claim of efficacy is made. Buyers, clients, and patients should ask, people in charge of deciding healthcare funding should ask, people in consumer-protection should ask, and people in anti-fraud should ask.

    If you want to make a claim, you should be ready to back it up with evidence and logical arguments - that's basic intellectual honesty.

    If you want to sell something that is purported to do a thing, you should be able to show that it does what you say it does - that's basic honesty.

    3. Then the Big Science gambit. People in ginseng and shiatsu do not have the resources to do studies and produce evidence, and scientists won't help them do it.

    First of all, both the ginseng business and shiatsu business are big business, and the alternative medicine business in UK and US are both multi-billion dollar industries.

    Secondly, go over to PubMed and search "ginseng" or "shiatsu" and you will find many articles on these two topics - scientists have studied these things, so sometimes it's not just an absence of evidence of efficacy, but evidence of absence of efficacy we are looking at.

    "Science" may not be easy or convenient, but it remains the best tool we have to test claims.

    4. Finally, your last paragraph implying that I am saying that "ginseng shouldn't be cultivated and shiatsu massage shouldn't be done" is just 'appealing to fear' - let angry doc apply science to what he wants and we will lose the liberty to plant ginseng and do shiatusu massage!

    I have of course never said anything like that. People are free to grow ginseng and do shiatsu massage, but as soon as they make claims for certain benefits which they cannot provide proof of, then I might just want to look at those claims on my blog.


    In short, you try to confuse the issue by implying that requiring people to provide evidence for the claims is:

    1. Restricting freedom of belief.
    2. Unfair to the party making the claim.
    3. Unfair to the Alterntaive Medicine industry because they lack the resources to conduct studies, and scientists won't help.
    4. Dangerous because it will result in restriction of our liberty.

    I hope I have shown that none of the above is true.

    By Blogger angry doc, At April 01, 2008 11:43 pm  

  • Then for the purposes of discussion, revise my sample views. Perhaps that ginseng will help cure erectile dysfunction or increase longevity or that shiatsu massage will alleviate back ache.

    Anyway ...

    A claim of efficacy may be made on many different grounds. For example, how may a beautician make a claim of efficacy for a particular kind of treatment?

    Perhaps she could explain where she learned about this kind of treatment; how long has this treatment been used by beauty spas; why it is supposed to work ... perhaps she could show "before" and "after" photos of her customers, or show testimonials. Perhaps she could offer one free trial to her current customers, and they can see for themselves.

    Not a "scientific" approach at all. The treatment may work, but this is not scientific proof. But why is no one complaining to the Ministry of Health about beauticians?

    And why should doctors necessarily be treated differently from the beauticians?

    (Bearing in mind that you and I are both discussing treatments which may or may not work - but will not cause harm).

    Now if you think about it, I believe the issue will likely boil down to one about how doctors should conduct their practice; whether or not as a matter of principle they should at all recommend procedures which are not scientifically substantiated etc. Perhaps some doctors feel that doctors should not behave like beauticians, perhaps some other doctors disagree. In other words, this is eminently a matter suitable for professional self-regulation and plenty of discussion within the profession itself. As opposed to direct government intervention.

    Now, the word "dishonesty" has appeared in your response. I think this is likely a misconception of your part.

    For example, the fact that certain common claims about ginseng or cordyceps or "cooling" Chinese herbal drinks are not scientifically substantiated does not mean that the seller or producer or promoter of such products is dishonest. The person may sincerely believe in the efficacy of such products. I am sure that your average TCM shop owner really believes in TCM. Therefore there is no question of dishonesty.

    IMO, and of course this is just my opinion, the large majority of GPs offering the treatments we'd been discussing probably do believe in the efficacy of the treatments, and are not dishonest (unless your profession really has sunk to low depths).

    Next, you have mentioned "intellectual dishonesty". Again, intellectual dishonesty arises when a person deliberately avoids certain known facts or deliberately twist them.

    But if a doctor chooses to explain a particular recommended procedure to the patient properly, then there is no question of intellectual dishonesty. For example, if the doctor says, "I wish to recommend you Procedure X. Personally I believe it works. But first let me also explain that there is little published scientific literature on its efficacy. You see, A, B, C ...", there is no intellectual dishonesty. It is up to the patient.

    By Blogger Gilbert Koh aka Mr Wang, At April 02, 2008 8:51 am  

  • OK, it seems now the discussion is about my use of the word "dishonest" and no longer burden of proof...

    For the part about doctors needing to self-regulating and to decide whether or not they should even offer unproven therapy etc. I agree with you.

    On the difference between beauticians and doctors, the law specifies which modalities of treatment beauticians are limited to, and these are held to the standard of 'OK unless harm done', while those used by doctors are held to 'OK only if proven safe'. That's the law. It is 'double-standards' and whether or not it should be so we may wish to discuss another time.

    As for the word "dishonest", I understand that your view is that if someone genuinely believes that something is true and he states it so, he cannot be called "dishonest" - the intention to deceive comes into the picture; I see your point and I think I should have used another term instead, maybe "intellectually sloppy".

    The question to my mind is whether anyone has good reasons to believe that his beliefs and claims are true. I don't think the "unscientific" ways of knowing mentioned by you constitute good reasons to believe or robust evidence to make claims on.

    Then there are those who continue to make certain claims after studies have failed to provide any proof of efficacy or indeed evidence contrary because they still sincerely believe in their claims. Are they "dishonest", or merely "misguided"?

    I reiterate my stand that science is the best tool to test any claim, and that I believe we should demand robust evidence when it comes to claims relating to healthcare. Conducting a scientific study doesn't always have to be difficult or expensive, as my other post yesterday shows.

    By Blogger angry doc, At April 02, 2008 9:51 am  

  • For example, how may a beautician make a claim of efficacy for a particular kind of treatment?


    Exactly. How can a beautician do that. Examine all the different ways a normal person might attest to the efficacy, and you will find ONLY one that actually works. That method is to do objective experiments and science.

    There is no other way.

    By Blogger Anders Brink, At April 02, 2008 12:12 pm  

  • "Then there are those who continue to make certain claims after studies have failed to provide any proof of efficacy or indeed evidence contrary because they still sincerely believe in their claims. Are they "dishonest", or merely "misguided"?"-Angry Doc.

    I can live with intellectually sloppy. :-)

    However, dopehead, idiot, faith-head or buffoon are more apt adjectives for people like Mr. Wang who not only believe but actually argue - with the requisite flaws - (don't these idiots ever learn to argue without fallacious reasoning?) for pseudo-science psychobabble.

    Frank Lee

    By Anonymous Anonymous, At April 02, 2008 1:27 pm  

  • "For example, if the doctor says, "I wish to recommend you Procedure X. Personally I believe it works. But first let me also explain that there is little published scientific literature on its efficacy. You see, A, B, C ...", there is no intellectual dishonesty..." - Mr. Wang

    Then that doctor is really saying that his belief in the efficacy of the recommended treatment is faith-based.

    He might just as well be saying that cow-dung taken from the magical fields of Jaipur when smeared on your head can cure migraine. I really, really believe it works.

    Let's face it, that is peddling "snake oil" based on cow-dung thinking. Such quacks have no business being in the medical profession.

    By Anonymous Anonymous, At April 02, 2008 2:38 pm  

  • Wow so much discussion!

    The only positive thing about using treatment that is not scientifically proven is that....

    We Spare The Animals (in the lab) From Agony By Sacrificing Ourselves!

    Ha Ha ha.....

    By Anonymous Anonymous, At April 02, 2008 3:23 pm  

  • Aiyah all this "science proven" efficacy claims can also change later on.

    What is "true" today may not be so 10 years later.

    This sort of debate will never end. Science is too sure of itself and needs to do so to preserve its intergrity. Not to unduly criticize the science system because they do contribute to society.

    However people are also free to have their own views be it mistaken, misinformed, wrong or right.

    Our society is based on the principle of freedom of choice. Even in many religions this is paramount.

    Freedom of choice means there is no such thing as an absolute.

    Of course scientists and mathematicians would argue there are absolutes.

    I think that there are fractals within each "absolute" such that it makes things very confusing.

    As it is this is only my view as well.

    Do you not agree that views and ideas are one of the foundation blocks of mankind? I wouldn't belittle views (even unsubstantiated ones)

    By Anonymous Anonymous, At April 03, 2008 11:57 am  

  • Mr. Wang says:

    "Next, you have mentioned "intellectual dishonesty". Again, intellectual dishonesty arises when a person deliberately avoids certain known facts or deliberately twist them."

    When a person makes a specific claim, the scientific method can be used to evaluate the actual veracity of that claim.

    For example, somebody may claim that you can increase the size and strength of your muscles by thought alone.

    But what happens if there is no evidence, or worse, that the evidence turns out to be contrary to the claim?

    It is indeed difficult, and sometimes impossible to know if the person is intellectually dishonest, wilfully ignorant, intellectually sloppy, or honestly mistaken.

    The only thing we know for sure is that the claim is wrong.

    By Blogger The Key Question, At April 03, 2008 12:35 pm  

  • anon,

    You are confusing opinions and views with facts. Everyone is entitled to his own opinion, but no one is entitled to his own facts. You may hold the opinion that you can leap tall buildings in a single bound, but until you can show that you can indeed do so, it remains an opinion and not a fact. Likewise a beautician may believe deeply that a certain cream will help remove wrinkles, but until it can be shown to do so, it remains merely a belief.

    Scienec is NOT "too sure of itself". That is a charge frequently laid against science by those who wish to discredit it, but the fact that you say that "[w}hat is "true" today may not be so 10 years later" shows that science continues to test claims and is willing to accept new evidence.

    I do not belittle "unsubstatiated" views, but I think we will be better off as a society if we can apply critical thinking to more aspects of our lives and require evidence for claims before accepting them.

    By Blogger angry doc, At April 03, 2008 12:40 pm  

  • In that case then angrydoc must definitely not be religious.

    Take it easy. I'm not trying to discredit anyone or anything.

    Just saying that it is a fact that in our society many people use opinions and beliefs over facts and objectivity when they make their decisions.

    Like it or not, right or wrong, I think it's a fact of life unfortunately.

    By Anonymous Anonymous, At April 03, 2008 3:54 pm  

  • I am amused that you assume that I will be offended by your saying that I am not religious.

    Yes, many people value opinions and beliefs over facts and objectivity, and ancedotes over evidence. One can either accept it as a "fact of life" which one cannot do anything about, or one can decide to do something to promote critical thinking and public understanding of science and scientific thinking. I choose to blog and help raise awareness.

    By Blogger angry doc, At April 03, 2008 4:17 pm  

  • It does not mean that if one does not embrace science then he is not capable of critical thinking and analysis.

    what I am merely saying is that the model of science (esp medical) which uses trials and statistical analysis of data derived from such studies has flaws of their own.

    I agree to a certain extent that in some instances some things may "work" but it is just that science has not found a way to "prove" that it works.

    Before Koch's postulates how did people base their "facts" on in the medical world? Experience?

    There might be better new ways to achieve "proof" of how some things work.

    You are right to say that science continues to try to update itself and strive to find more answers for every question.

    However we live in the NOW where we sometimes cannot wait for science to finally find that answer. In a way by trying something, we will know what the answer is for our individual selves. Of course one anecdotal report on ONE patient does not equate to FACT OF PROOF by science's standards.

    But to that patient....IT WORKS. If the patient did not try......of course there might be risks involved eg danger of the treatment etc.

    It might be better for science to prove whether certain "unproven" treatments are dangerous than to prove that they work. Might benefit society in the shorter term much more.

    By Anonymous Anonymous, At April 03, 2008 4:32 pm  

  • Anon 3:54 says:

    "Just saying that it is a fact that in our society many people use opinions and beliefs over facts and objectivity when they make their decisions.

    Like it or not, right or wrong, I think it's a fact of life unfortunately."

    Indeed it is a matter of individual freedom for a person to make her/his personal decisions based on either opinions or facts.

    However, that is not the case if you are making recommendations for others - to be a credible source you should base your assertions on fact.

    Let me illustrate this with a quote about Richard Feynman:

    There were 183 of us freshmen, and a bowling ball hanging from the three-story ceiling to just above the floor. Feynman walked in and, without a word, grabbed the ball and backed against the wall with the ball touching his nose. He let go, and the ball swung slowly 60 feet across the room and back — stopping naturally just short of crushing his face. Then he took the ball again, stepped forward, and said: "I wanted to show you that I believe in what I'm going to teach you over the next two years."

    It's not only about belief, but belief based on demonstrable facts.

    You are right that it is unfortunate that there are people who prefer unsubstantiated views over facts, and worse, recommend these views to others.

    This practice should be discouraged.

    By Blogger The Key Question, At April 03, 2008 4:54 pm  

  • "There might be better new ways to achieve "proof" of how some things work."

    Really? Like what?

    "Before Koch's postulates how did people base their "facts" on in the medical world? Experience?"

    Yes, and that was why there was all that blood-letting and induction of 'purging'. Aren't you glad we've come away from all that?

    "In a way by trying something, we will know what the answer is for our individual selves."

    Well, that's how homeopathy started...

    "But to that patient....IT WORKS. If the patient did not try..."

    There are a number of reasons why a patient may *think* that a particular treatment works, when in reality it does not, or that it was some other factor which gave relief to his condition. That is why we have randomised controlled trials with proper blinding.

    "It might be better for science to prove whether certain "unproven" treatments are dangerous than to prove that they work. Might benefit society in the shorter term much more."

    Or it might just create a whole host of treatment that are harmless and also useless, making it harder for patients to know what the best option is. I think the current system of requiring treatment to both be safe and effective is pretty sound.

    By Blogger angry doc, At April 03, 2008 4:57 pm  

  • Anon 4:32 says:

    "I agree to a certain extent that in some instances some things may "work" but it is just that science has not found a way to "prove" that it works."

    To believe something before the evidence is available, is a practice that should be discouraged.

    "There might be better new ways to achieve "proof" of how some things work."

    Is there a better way, outside of rational inquiry and empirical data? I await your suggestion.

    "However we live in the NOW where we sometimes cannot wait for science to finally find that answer. In a way by trying something, we will know what the answer is for our individual selves. Of course one anecdotal report on ONE patient does not equate to FACT OF PROOF by science's standards.

    But to that patient....IT WORKS. If the patient did not try......of course there might be risks involved eg danger of the treatment etc.

    It might be better for science to prove whether certain "unproven" treatments are dangerous than to prove that they work. Might benefit society in the shorter term much more."

    Hmm... interesting.

    I guess the question for you is: would you be willing to bet your life on that one anecdote?

    If not, how would you justify betting the life of anyone else?

    Note that determining the safety of any treatment is not a one step process - it is practically impossible to know the accurate risks and dangers of any treatment based on one anecdote.

    By Blogger The Key Question, At April 03, 2008 5:12 pm  

  • "Hmm... interesting.

    I guess the question for you is: would you be willing to bet your life on that one anecdote?

    If not, how would you justify betting the life of anyone else?"

    I would if I was already doomed to dying (eg Stage IV cancer) and money was not a concern for me. What's there to lose?

    You are referring to LIFE SAVING/LIFE THREATENING procedures.

    I wasn't talking about that in my previous comment.

    Why must bet life so serious? Eg Mr Wang's comment about taking ginseng for good health....BET LIFE ar?

    Don't exaggerate and make this discussion something else it isn't please.

    By Anonymous Anonymous, At April 03, 2008 6:39 pm  

  • Just a point here about science.

    While we talk about how we must have proof before starting people on treatment that is not proven etc...the FACT is we DO put some people on treatment that is not proven on a regular basis.

    It's called trials. While there are various stages for clinical trials, when they do get to testing on humans it is still dangerous. But some people still volunteer for it.

    Some pay with their lives even!

    Yet this is still done. Of course there is no other way.

    The point I am trying to make is that, there are different levels of "trials". And again it is the individual who makes that choice out of free will to try or trial that treatment or procedure for whatever reasons they may have. Be it furthering science, or having a last hope, or simply being curious, it is free will.

    Should we protect people from dangerous treatments that can harm them? Yes we should. Should we protect people from products and services that do not work and are a total waste of money? Well ideally we should. But the task is enormous and simply not economical.

    I'll give you an example from the financial world. Elliot Wave theory. Is this proven by science? Nope. Do traders use it? Some do.

    Technical analysis. Proven by science? Still debatable. Used by traders? Yes.

    So should the authorities stop the sale of these technical analysis books and Elliot wave theory books that spread "unproven" techniques for trading which might cause individuals to lose their entire life savings?

    Well going by your arguments, it seems the authorities should ban them.

    Similarly for all those books in the bookstores on alternative medicine and the like.

    I know your motives are noble, but I think there is an extent to which one can go in controlling these things.

    I am all for banning dangerous medical related treatments. And I think FDA does this job. As for useless treatments...well think of Vytorin and how many people have WASTED their money on it.

    It's never perfect anyway. So why make it sound like the "science" system is so superior?

    By Anonymous Anonymous, At April 03, 2008 6:49 pm  

  • "So why make it sound like the "science" system is so superior?"

    Because it works.

    And you still haven't answered our question on what your "better new ways to achieve "proof" of how some things work" are.

    By Blogger angry doc, At April 03, 2008 6:54 pm  

  • "...the FACT is we DO put some people on treatment that is not proven on a regular basis.

    It's called trials."

    Yes, we do put people on trials, and as you noted trials undergo several stages during which the plausibility of the treatment tested, the safety profile tested, and data collected for statistical analysis so meaningful information can be collected. Trials have been stopped mid-way when it is found that a form of treatment is not efficacious or indeed safe. This kind of rigour is not applied to many forms of unproven therapy before they are allowed to be sold to the public, so conducting trial is not the same thing as endorsing or selling unproven therapy.

    I cannot comment on economic theories intelligently since I am not familiar with them, but books on alternative medicine is perhaps something I should look into someday. Suffice to say now that it is possible for many authors to make claims without providing evidence because of the 'First Amendment Rights' - google "Kevin Trudeau" for an illustration of this phenomenon.

    "I know your motives are noble, but I think there is an extent to which one can go in controlling these things."

    I'm glad you appreciate what Leng Hiong and I are trying to do here, but I don't share your pessimism on what can be done. Legislation is one way (Mdm Halimah Jacob just made a comment proposing beauticians be regulated, so progress can be made), but what is more important to me is that we all get into the habit of examining claims critically and requiring evidence for them. We may not be able to legislate against all forms of unproven therapy or eliminate gullibilty, but we can try to make the public more discerning.

    By Blogger angry doc, At April 03, 2008 7:11 pm  

  • Anon 6:39 says:

    "Why must bet life so serious? Eg Mr Wang's comment about taking ginseng for good health....BET LIFE ar?

    Don't exaggerate and make this discussion something else it isn't please."

    Hmm... am I exaggerating?

    Perhaps you are claiming that ginseng has no side effects.

    http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-ginseng.html

    Note that:

    Based on human research, ginseng may lower blood sugar levels. This effect may be greater in patients with diabetes than in non-diabetic individuals. Caution is advised in patients with diabetes or hypoglycemia, and in those taking drugs, herbs, or supplements that affect blood sugar. Serum glucose levels may need to be monitored by a healthcare provider, and medication adjustments may be necessary.

    In addition:

    A severe life-threatening rash known as Stevens-Johnson syndrome occurred in one patient and may have been due to contaminants in a ginseng product. A case report describes liver damage (cholestatic hepatitis) after taking a combination product containing ginseng. High doses of ginseng have been associated with rare cases of temporary inflammation of blood vessels in the brain (cerebral arteritis), abnormal dilation of the pupils of the eye, confusion, or depression.

    Please explain to us how a single anecdote can produce the safety data on this patient information page.

    Maybe then it would be clearer how a single anecdote can determine the effectiveness of any treatment.

    By Blogger The Key Question, At April 03, 2008 7:27 pm  

  • Hi Mr Lim,

    Your examples are not reflective of the realities.

    Ginseng is used very widely by many people all over the world. You are talking about Stevens-Johnson syndrome as a way to say that Ginseng has to be classified as poison perhaps?

    Stevens-Johnson Syndrome while being extremely dangerous can be caused by a variety of common drugs. Eg NSAIDs being a very common one. Bactrim is another that comes to mind.

    Are these drugs still widely used for analgesia and antibacterial treatment? Yes they are. Will every patient get SJS? Unlikely. Will some get it? Yes they will. Do we know who will get it? No we don't. Why scare people about ginseng resulting in SJS when you can give so many more examples of common drugs that cause it too?

    As for the point about hypoglycemia from ginseng use......you may have a point. But it would be interesting to see the actual incidence of such events in populations.

    Peanuts can cause severe allergies resulting in death in quite a large number of people especially caucasians who give their little children peanut butter from a young age.

    Should peanut butter and peanuts be prescription only?

    We have to have some balance here lah.

    You are being too extreme.

    There is a supplement called Pharmaton which is panax ginseng extracts. If indeed ginseng is so dangerous I am sure HSA should have pulled this product off the shelves of health food stores. And I do trust that HSA does their job in monitoring reports of adverse reactions from doctors.

    If indeed the incidence of ginseng linked SJS is high enough then HSA would do their job.

    You say unscrupulous people use exaggerated claims to sell products and services. Well you seem to be using similar exaggerated scare tactics also what!

    Don't lah.

    By Anonymous Anonymous, At April 03, 2008 10:25 pm  

  • And you still haven't answered our question on what your "better new ways to achieve "proof" of how some things work" are.

    By Blogger angry doc, At April 03, 2008 10:35 pm  

  • "On the difference between beauticians and doctors, the law specifies which modalities of treatment beauticians are limited to, and these are held to the standard of 'OK unless harm done', while those used by doctors are held to 'OK only if proven safe'. That's the law."

    Which law, please? I am not aware. If this is already a law, then I shall alert the Attorney-General's Chambers to immediately prosecute all those doctors which we have been discussing.

    No need for Khaw to pass any new regulations. After all, according to you, the laws already exist.

    By Blogger Gilbert Koh aka Mr Wang, At April 04, 2008 8:48 am  

  • Thought I shall offer you another simple way to look at it.

    Suppose Dr Tan runs a full-time clinic, and also offers scientifically unsubstantiated aesthetic treatments not known to be harmful. This you object to.

    Now, suppose Dr Tan decides to stop offering those treatments (no doubt this pleases you), and also decides to run his clinic only part-time.

    On other days, he runs another business with his wife at another location, called "Tan's Beauty Parlour". Besides facials and massage services and training in grooming, he also offers the same scientifically unsubstantiated aesthetic treatments that he used to offer at his clinic.

    Presumably you would not object to this (as I do not hear you objecting against beauticians' businesses generally).

    So you see - your real objection is not to the treatment. Your real objection is based on your own ideas on what doctors should or should not do.

    So please stop deluding yrself that your views are just based on "scientific" considerations.

    By Blogger Gilbert Koh aka Mr Wang, At April 04, 2008 9:36 am  

  • Gee, Mr Wang, why are you putting the burden of proof on me?

    Well the laws are found in the Medicines Act and the Private Hospital and Clinic Act.

    By Blogger angry doc, At April 04, 2008 9:37 am  

  • Next example - suppose a beautician or doctor offers a scientifically unsubstantiated beauty treatment not known to be harmful.

    According to a Straits Times article, 40 customers surveyed said that they are extremely pleased and happy. They report no complications and furthermore say that the results are excellent.

    No doubt you will say that these claims of efficacy are very unscientific and unreliable. To establish the efficacy, we need clinical trials; controlled studies; large sample size; published papers etc, before we conclude that the treatment works.

    But suppose the following week, the straits times then reports that one customer underwent the same treatment, and immediately developed severe rashes, itches etc.

    Will you say that these allegations of harm are also unscientific and unreliable? And that we need clinical trials; proper controls; big sample size; published papers etc, before we can scientifically and reliably conclude that the treatment is harmful?

    I would say that you are stupid. Scientific, but stupid.

    By Blogger Gilbert Koh aka Mr Wang, At April 04, 2008 9:53 am  

  • "Presumably you would not object to this (as I do not hear you objecting against beauticians' businesses generally).

    So you see - your real objection is not to the treatment. Your real objection is based on your own ideas on what doctors should or should not do.

    So please stop deluding yrself that your views are just based on "scientific" considerations."

    Well, I haven't blogged about ear-candling yet, but that doesn't mean I think it is OK.

    And I have blogged about fengshui and exorcism, which are not about doctors' bahaviour, so I'm not all about what doctors should or should not do either.

    By Blogger angry doc, At April 04, 2008 9:55 am  

  • I just perused both Acts.

    I don't see where it says that doctors cannot offer treatments the efficacy of which is not scientifically substantiated, and which are not known to be harmful.

    Seriously, if you believe otherwise and you think that these doctors have committed criminal offences, do be a good citizen and go make a police report.

    By Blogger Gilbert Koh aka Mr Wang, At April 04, 2008 10:04 am  

  • "On the difference between beauticians and doctors, the law specifies which modalities of treatment beauticians are limited to, and these are held to the standard of 'OK unless harm done', while those used by doctors are held to 'OK only if proven safe'. That's the law."

    I'm sorry if you got the impression that I said the law prohibits doctors from providing unsubstantiated treatment, but what I said about the law related to the issue of safety, not efficacy.

    By Blogger angry doc, At April 04, 2008 10:42 am  

  • "But suppose the following week, the straits times then reports that one customer underwent the same treatment, and immediately developed severe rashes, itches etc.

    Will you say that these allegations of harm are also unscientific and unreliable? And that we need clinical trials; proper controls; big sample size; published papers etc, before we can scientifically and reliably conclude that the treatment is harmful? "

    It depends on the specific circumstances, of course, but if you are trying to say that drugs are pulled off the market based on one single case of adverse reaction then no, that's not how it works.

    Monitoring adverse drug reaction is a process of collecting data and analysing them.

    Drugs with known adverse reaction are not automatically pulled off the market, but can still be used depending on the risk-benefit ratio. And to know risk benefit ratio requires that we have data on the risks and benefits.

    It's still science, and I'm not sure it's stupid.

    By Blogger angry doc, At April 04, 2008 10:52 am  

  • Mr. Wang said.

    "Next example - suppose a beautician or doctor offers ...

    No doubt you will say ...

    But suppose the following week, the straits times then reports ... etc.

    Will you say ...

    I would say that you are stupid. Scientific, but stupid."

    Hi Mr Wang,

    Doncha just love the way you set up your own straw-men and then proceed to beat them up?

    Poor Angrydoc, he keeps having to take your words out from his mouth.

    PZ

    By Anonymous Anonymous, At April 04, 2008 10:54 am  

  • A.D:

    But it has been clear all along that we are talking about treatments not scientifically substantiated for efficacy, and not known to be harmful. Khaw has already stated that if the treatment is known to be harmful, the ministry WILL intervene. You quoted khaw on your own blog, remember?

    So I do not know why you suddenly introduce "safety" into the present discussion.

    If "safety" is your concern, then surely beauticians must be held to the same standards as doctors, for the same kind of treatment.(Or if you prefer, doctors must be held to the same standards as beauticians).

    By the way, if one of those aesthetic treatments is reported by patients to cause adverse reactions, I would want the ministry to intervene immediately. I would not expect the ministry to wait for a few years while the treatment is being scientifically researched in clinical trials etc to verify the allegations of harmful effects. Sorry for my "unscientific" and "intellectually sloppy" stand on this.

    By Blogger Gilbert Koh aka Mr Wang, At April 04, 2008 12:06 pm  

  • Anon 10:25 says:

    "Your examples are not reflective of the realities."

    Are you trying to say that I'm making all this stuff up? Don't ask me, ask NIH (USA).

    *shrugs*

    "Ginseng is used very widely by many people all over the world. You are talking about Stevens-Johnson syndrome as a way to say that Ginseng has to be classified as poison perhaps?"

    But ONE patient developed Stevens-Johnson syndrome after taking ginseng!

    Recall that you said:

    "However we live in the NOW where we sometimes cannot wait for science to finally find that answer. In a way by trying something, we will know what the answer is for our individual selves. Of course one anecdotal report on ONE patient does not equate to FACT OF PROOF by science's standards.

    But to that patient....IT WORKS."

    Based on your idea, it should be considered a poison because to that ONE patient....it is dangerous.

    I'm just taking your approach to its logical conclusion.

    "Stevens-Johnson Syndrome while being extremely dangerous can be caused by a variety of common drugs. Eg NSAIDs being a very common one. Bactrim is another that comes to mind.

    Are these drugs still widely used for analgesia and antibacterial treatment? Yes they are. Will every patient get SJS? Unlikely. Will some get it? Yes they will. Do we know who will get it? No we don't. Why scare people about ginseng resulting in SJS when you can give so many more examples of common drugs that cause it too?"

    Observe that the safety data that you mention here was discovered by scientific methods.

    Also observe that you are supporting your stand by using evidence, rather than opinions.

    So although you assert that...

    "There might be better new ways to achieve "proof" of how some things work."

    ...you certainly didn't use the "better new ways" in your discussion.

    And we still don't know what they are.

    "As for the point about hypoglycemia from ginseng use......you may have a point. But it would be interesting to see the actual incidence of such events in populations."

    Requires science.

    "Peanuts can cause severe allergies resulting in death in quite a large number of people especially caucasians who give their little children peanut butter from a young age."

    Revealed by science.

    "There is a supplement called Pharmaton which is panax ginseng extracts. If indeed ginseng is so dangerous I am sure HSA should have pulled this product off the shelves of health food stores. And I do trust that HSA does their job in monitoring reports of adverse reactions from doctors.

    If indeed the incidence of ginseng linked SJS is high enough then HSA would do their job."

    Yup, you need science for that too.

    "You say unscrupulous people use exaggerated claims to sell products and services."

    No I didn't. You can search the entire comments section.

    "Well you seem to be using similar exaggerated scare tactics also what!"

    To address your claim that you can determine whether a treatment works with a single case, all I need to do is to show any example where a single case does not give you an accurate overall picture of the treatment, be it efficacy or safety.

    You claim that I am exaggerating because you want to think (or want others to think ) that I am suggesting that ginseng is harmful for most people.

    Actually, my claim is simply that ginseng has side effects for some people.

    By Blogger The Key Question, At April 04, 2008 12:37 pm  

  • "But it has been clear all along that we are talking about treatments not scientifically substantiated for efficacy, and not known to be harmful...

    So I do not know why you suddenly introduce "safety" into the present discussion."

    I brought up the point to show that the law holds doctors and beauticians to different standards, and as you point out regards safety and not efficacy.

    To clarify: I think both should be held to the same standards regarding efficacy and safety.

    By Blogger angry doc, At April 04, 2008 12:48 pm  

  • "By the way, if one of those aesthetic treatments is reported by patients to cause adverse reactions, I would want the ministry to intervene immediately. I would not expect the ministry to wait for a few years while the treatment is being scientifically researched in clinical trials etc to verify the allegations of harmful effects. Sorry for my "unscientific" and "intellectually sloppy" stand on this."

    Application of science doesn't mean that we take years to act on a single report of adverse reaction (strawman again, Mr Wang) - it just means that we "individually reviewed with particular attention to the serious adverse reactions reports" instead of concluding immediately that an adverse reaction is due directly and/or only to the treatment implicated.

    You can find out more about the process from the Health Sciences Authority site:

    http://www.hsa.gov.sg/publish/hsaportal/en/health_products_regulation/safety_information/report_adverse_reaction.html

    This process, along with the collection and analysis of data on reported ADR ensures that we do unnecessarily pull off drugs which are proven to be useful based on mis-attributed adverse effects, or create unneccesary panic, as is with the case of the MMR scare.

    By Blogger angry doc, At April 04, 2008 1:05 pm  

  • "To address your claim that you can determine whether a treatment works with a single case, all I need to do is to show any example where a single case does not give you an accurate overall picture of the treatment, be it efficacy or safety.

    Otherwise also known as the "Hasty Generalization" Fallacy.

    Am I the only one who notice a pattern here? Those people who advocate pseudoscience/faith-based beliefs and pooh pooh the scientific method usually confirm their intellectual sloppiness by using bad argument with flawed reasoning.

    Misguided? Nah. More like dopey or loopy.

    By Anonymous Anonymous, At April 04, 2008 1:47 pm  

  • Good, Angry Doctor. Now at least there is consistency in your position. I appreciate that.

    Why aren't you writing to Khaw Boon Wan to shut down beauty parlours, Phillip Wain, The Body Shop and Guardian Pharmacy, or at least to stop them from offering products / services which are not scientifically substantiated to be safe?

    Because - seriously speaking, and no sarcasm intended - as a medical professional, if you HONESTLY feel that all these products and services really pose such a (potential or actual) hazard, SHOULDN'T you be VERY concerned? Why aren't you calling for government regulation on shampoos, for instance? They are aesthetic products; many will make claims to make your hair shiny, healthy and beautiful - I'm sure we must agree that most of these claims are not, in practice, scientifically substantiated.

    What brand of shampoo do you personall use, AD? Did you check to see if it has been scientifically substantiated to be harmless to users? Aren't you afraid that it might cause your health severe damage?

    By Blogger Gilbert Koh aka Mr Wang, At April 04, 2008 2:57 pm  

  • "Why aren't you writing to Khaw Boon Wan to shut down beauty parlours, Phillip Wain, The Body Shop and Guardian Pharmacy, or at least to stop them from offering products / services which are not scientifically substantiated to be safe?"

    Because the government is aware of the discrepancy in standards and the double-standards, and its position is to 'strike a balance' between consumer protection and business (I noted this on a previous entry on Health Products Act). The double-standard follows that of the US FDA, while the position of balancing business and consumer protection follows a US Court decision (if I recall correctly).

    I continue to raise the issue on my blog, and while I am not sure it is having any effect, I am glad that Halimah Yacob seems to think that this double-standard needs to be addressed.

    I use a pharmacy-only medicated shampoo, so yes, it is certified safe. :)

    There are government regulations against false advertising for shampoo and cosmetics though, so if you look closely at shampoo and cosmetics advertisements you will find a disclaimer or clarification in small print in the corner of your screen. For instance, if the voice-over says a product "deeply penetrates the skin to nourish" you will see a disclaimer saying that "skin" here refers to the epidermis, and of course there is no scientific definition of "nourish". And in another one saying "90% of women experience improvement", you will find the small print clarifying that the sample size is only maybe 20 women. Likewise for those herbal balding remedies you find disclaimers that there is no evidence that they work, usually flashed at the bottom of the screen in small print in the final second of the ad. How many people actually notice these caveats?

    There are also certain diseases and conditions which health products cannot claim to treat or cure - your ginseng for erectile dysfunction is one example. Of course the people who sell these products get around the problem by avoiding the use of the term "erectile dysfunction", and substituting words which hint at increasing sexual prowess. There are also numerous products which claim to 'detox' the body, without specifying what toxins exactly they are referring too and how they are removed from the body.

    The laws are there, but how robust or effective they are is another thing.

    By Blogger angry doc, At April 04, 2008 3:36 pm  

  • Mr Wang fails to recognize that there is a fundamental difference between beauticians and doctors. Similarly those people who say patients must practise caveat emptor ('buyers beware') when they consult doctors who practise aesthetic medicine are off the mark. You should practise caveat emptor when you buy a face cream or visit a beautician. The doctor-patient relationship cannot be based on caveat emptor...it is based on trust. The doctor has the ethical and professional duty to ensure that he provides evidence-based advice and treatment to his patients. That sets us apart from beauticians, snake oil sellers and TCM practitioners. It is about trust, the fundamental tenet of the doctor-patient relationship. If we lose that, the medical profession loses its higher standing in society. And that's why I think the Ministry should ban doctors from practising so-called aesthetic medicine.

    By Anonymous Anonymous, At April 05, 2008 8:55 pm  

  • hi angry doc,

    nice to see you are back! keep up the good work dude!

    By Anonymous Anonymous, At April 07, 2008 7:04 pm  

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