Wednesday, April 29, 2015

The NECSS of Thought and Reality - Year 5 (Part 1)

This year marked the seventh annual Northeast Conference on Science and Skepticism (NECSS) on April 9-12. Held in New York City, NECSS brings together people from all manner of backgrounds to spend a few days learning about science, critical thinking and how to improve our communities through education and outreach. It is a joint venture by the New York City Skeptics and The New England Skeptical Society. This was the fifth year I've attended, and just like in past years, it blew me away. Over 500 people attended this year's conference from at least 30 states and a dozen countries. If you're interested in past years' conferences, see my reviews from 2011, 2012, 2013 (part 1 and part 2), and 2014 (part 1 and part 2). If you were not able to attend and would like to see the presentations, they will be uploaded to the NECSS YouTube channel, where you can also view presentations from previous conferences.

I always take my NECSS review as an opportunity to revisit what "skepticism" means, what it means to be a part of the "skeptical community". Skepticism isn't what you think, but rather how you think about the world around you. A core principle of skepticism is that you should always accept the possibility that you could be wrong. The world is so incredibly complex that we cannot know everything individually, so when we observe some event or read a web site, any conclusions we make are provisional. New evidence may support those conclusions, or it could completely overthrow our viewpoint. To be skeptical, then, is to ask questions, to investigate, to weigh the evidence presented, to come to conclusions supported by good evidence and to be willing to admit mistake and change our stance. Skepticism is not simply the rejection outright of claims with which we disagree simply because we do not like them. And the skeptical community is really just the broader collection of normal individuals who view the world through that skeptical lens. We are parents, children, teachers, students, scientists, laborers, doctors, patients, lawyers, desk jockeys, engineers. We are rich. We are poor. We live in cities and in the countryside. We come from all over the world. In short, we are people striving to improve ourselves and the world around us.

For those who have never been to NECSS, not only is it a great opportunity to learn a lot of new things, but there are a lot of great people to meet and new friendships to forge. My experience has been that everyone is generally pretty open to being approached. The conference provides ample opportunity to socialize outside of the talks. I've made a number of new friends there, and it's a great chance to reconnect with people you otherwise don't see frequently.

On with the conference.

Lobby with Sponsor Tables
As with the past two years, NECSS 2015 was held at the Fashion Institute of Technology. This year, the venue was back in the Haft Auditorium, which I noted before was one of the best locations so far for the conference. The auditorium has raked theatre seating and good lighting control, and the separate lobby provides a nice area for the sponsors to set up tables where attendees can relax and chat without disrupting the talks. FIT is also very conveniently located, being only a few blocks from Penn Station and surrounded by plenty of restaurants and hotels.

The overall schedule has been gradually expanding over the past several years. This year, in addition to a full day of workshops (which I was unable to attend) and the normal two full days of panels and individual speakers, the organizers added a full day of talks by the Society for Science-Based Medicine, who also helped co-sponsor the conference this year. As an aside, if you care about the quality of medicine and health care, whether you have a medical background or not, I highly recommend joining the Society and learning how you can get involved. The four-day schedule allows for a lot of content to take in, but comes with the down side of the added expense of extra nights for a hotel and days off of work. A couple members of the New York City Skeptics were thinking that some sort of apartment sharing could help make it easier for people to attend. Sort of an "adopt-a-skeptic" kind of thing.

Day 1
Steve Novella - Science-Based Medicine: Going Beyond Evidence-Based Medicine

The first day of talks, focused on science-based medicine (SBM), opened with Dr. Steve Novella discussing why we need SBM and how eveidence-based medicine falls short. Most of the information on the internet today deals with health and medical information, and much of it is misleading (e.g., Dr. Oz). Critical thinking, Dr. Novella says, is its own skill set and is vital for both professionals and the public to be able to navigate the information is out there. About 20-25 years ago, evidence-based medicine came on the scene to try to improve the quality of information. While it has a number of good elements, it still needs improvement, as it focuses too much on clinical evidence and ignores prior plausibility. Most published clinical studies, particularly preliminary investigations, come to the wrong conclusions, and it can take decades for the literature to coax out the truth.

There are a few reasons that early studies can be wrong. Individual studies can be easily manipulated, whether by engaging in questionable practices like inappropriate subgroup analyses or through innocent mistakes. Journal practices can also skew the published literature. Open access journals tend to be pay-to-play and have poorer peer review. High impact journals like Science, Nature, or Cell are motivated by provocative, cutting edge studies, which are the very type most likely to be wrong. It takes the totality of the scientific literature, especially follow-up studies and replications to get a better sense of what the evidence really says. As studies improve (better sample sizes, tighter controls, etc.), the effect sizes tend to disappear.

Dr. Novella pointed to a 2009 Cochrane review of oscillococcinum (since withdrawn), a homeopathic concoction, as an example of these problems with evidence-based medicine. The Cochrane review concluded that the product was promising, but there was insufficient evidence to warrant recommending its use. Not only did the review ignore the improbable nature of the medicine (i.e., the main ingredient being diluted so much that not a single molecule was likely to remain), but it ignored the fact that oscillococcinum doesn't even exist. As Dr. Novella put it, it's the "equivalent of fairy dust diluted out of existence".

In the end, Dr. Novella suggested that we're probably adopting treatments too soon, and that focusing on the science, rather than merely the evidence, can help improve the overall quality of medical information available to professionals and the public.

Harriet Hall - Chiropractic: Not All It's Cracked Up to Be
Dr. Harriet Hall
Of all of the complementary and alternative medical treatments out there, chiropractic is the most widely used. Some people even go to chiropractors for all of their health needs, even though chiropractic is based on a myth. The origin, as Dr. Harriet Hall relates, occurred when the founder of chiropractic, D. D. Palmer, claimed to have cured a janitor's deafness by manipulating his spine. Not only is that biologically implausible, since none of the auditory nerves run through the spine, but the janitor's relatives wrote that he remained deaf until the day he died.

In Palmer's time, the germ theory of disease was not widely accepted yet. Vitalism, the belief that imbalances in the humours caused illness, still influenced public thinking about health. It's not surprising that Palmer would think subluxations, or displacement of a bone, impinging on nerves would block the flow of nerve impulses like the kink in a hose. But nerve impulses are electrical; they don't flow like water. While subluxations are real and are easy to spot on an x-ray, chiropractic subluxations don't show up on x-ray. The location of a chiropractic subluxation changes depending on the chiropractor doing the examination. A further difference between real medicine and chiropractic is that real medicine discards what doesn't work. Chiropractic simply adds more and more techniques without discarding anything.

So does chiropractic work and is it safe? Dr. Hall agrees that it can work for back pain, though no better than physical therapy. Problems arise, however, when chiropractic is applied to the neck, often involving rapid twists that can damage the blood vessels passing through the neck. Although uncommon, these maneuvers case about 1,300 strokes per year. Dr. Hall related the stories of Sandra Nette (link goes to YouTube and may be difficult for some people to watch) and Laurie Jean Mathiason. Sandra was healthy, but thought that she needed chiropractic to remain healthy. Her chiropractor did a rapid neck manipulation, after which Sandra said she felt dizzy. The chiropractor did not recognize that she was having a stroke that ultimately left her paralyzed. Laurie Jean received 186 neck manipulations over 6 months for lower back pain. The final manipulation caused her to go into a coma on the chiropractor's table. She died three days later due to a "traumatic rupture of the left vertebral artery".

Dr. Hall related that while chiropractors have been trying to expand their scope of practice, even so far as to become primary care doctors, they lack the required training. The field attracts quackery like the Toftness device, applied kinesiology and pendulum divination, among others. Chiropractors also tend to be unable to properly diagnose patients. In one study, according to Dr. Hall, a fake patient went to multiple chiropractors claiming symptoms associated with heart failure. All of them missed the correct diagnosis and recommended manipulation for pain. Some strongly advocate for neck manipulation of children and even newborns. But, Dr. Hall says, "No child under 12 should get chiropractic treatment for any reason. Period." While some "reform" chiropractors reject the idea of subluxations and operate more as physical therapists, they are a minority.

Dr. Hall closed with the story of a child who had bacterial meningitis. Instead of being treated with antibiotics, the child received chiropractic adjustments. Left untreated, the infection killed the child. In that case, the family did not end up suing the chiropractor, because the chiropractor was the child's own father.

David Gorski - Integrative Medicine: Integrating Cow Pie with Apple Pie

Dr. David Gorski
Dr. David Gorski opened his talk with a brief history of Integrative Medicine. What began (and arguably still is) quackery has undergone several name changes over the years, from "alternative medicine" to "complementary and integrative medicine" to "integrative medicine". A fair amount of this changing identity was driven by Dr. Andrew Weil, the "guru of integrative medicine". The push to rebrand CAM modalities has been so successful that even the National Center for Complementary and Alternative Medicine changed its name to the National Center for Complementary and Integrative Health.

What does integrative medicine actually include? In addition to what Dr. Gorski describes as Trojan Horse subjects like nutrition, exercise (yoga), and some natural products that have pharmacological effects, IM includes traditional Chinese medicine, reiki (a Japanese version of faith healing), naturopathy, acupuncture, homeopathy, and so forth. Naturopathy, for example, has come up with numerous false diagnoses and corresponding treatments that span the gamut of CAM treatments despite lacking scientific support.

One of the more depressing aspects of Dr. Gorski's talk was that there are at least 100 CAM courses in the U.S. as part of the required curriculum. This wouldn't be a bad thing except that the courses are taught from a credulous perspective. There are even integrative medicine residencies and board certifications (though, as Dr. Gorski noted, no certifications from the official certifying body that governs legitimate specialties like internal medicine or pediatrics). IM is essentially the medicalization of supportive therapies like stress reduction, music, and relaxation, combined with the insertion of rank quackery into real medicine. As Dr. Gorski's colleague at Science-Based Medicine, Dr. Mark Crislip, likes to describe it, "If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse."

With so many institutions, some of them highly respected ones, beginning to open integrative medicine centers, Dr. Gorski described science-based medicine as the Rebel Alliance against the Galactic Empire.

Mark Crislip - How Acupunctures "Work"

Dr. Mark Crislip
No, that's not a typo in the title of Dr. Mark Crislip's talk. The final talk of the morning, Dr. Crislip discussed acupuncture. Or rather, acupunctures. The first question to ask in any discussion of whether acupuncture "works" is to find out which one. There are a wide variety of acupuncture styles: Chinese, Japanese, east, tongue, head, feet, laser, electro-, moxibustion, cupping, music, and Tong Ren (in which a doll, rather than the patient, is struck at specific points with a silver hammer).

Dr. Crislip summarized how acupuncture seems to work. Although it does not produce improvements in objective measures, subjective outcomes, such as perception of pain, might be affected. Some studies show that this can be driven by patient expectation. If the patient believes that their symptoms will improve, they perceive comparable improvements. If they do not believe, they do not see improvement. What's more, any improvements seen don't have any connection with where needles are inserted, nor even if the skin is pierced by the needles at all.

The most interesting part of Dr. Crislip's talk came when he discussed the rubber hand effect. Briefly, if a rubber hand is placed so it appears as if it is part of the patient's body, and the corresponding hand is hidden from view, the patient's brain can be tricked into "feeling" things applied to the rubber hand, for instance, cold when an ice cube touches it. Rubber hands have no nerves, no acupuncture meridians, no connection at all with the patient, yet acupuncture needles inserted into the rubber hand can produce the same fMRI changes in the brain as if needles were inserted into the patient's actual hand. (Then again, improperly controlled fMRI can also show brain activity even when the brain cannot be active, such as in a deceased salmon.) Studies such as this show that acupuncture is nothing but an elaborate theatrical experience with no real connection to needles, meridians or anything else.

The bottom line is that in any objective sense, acupuncture doesn't work. Expectation's the thing, not how or even if acupuncture is done. Dr. Crislip has a blog post up expanding on this a bit.

Jann Bellamy - Political Pseudoscience

Jann Bellamy, JD
Attorney Jann Bellamy started out the afternoon with a talk about the legal landscape of medicine and quackery, focusing on health care practice (HCP) acts. The first HCP acts came about in the late 1800s. Medical practice of the time was not regulated, and pretty much anyone could call themselves a doctor and practice medicine. In the medical profession, however, there were those with actual training in the healing arts and "irregulars" (homeopaths, faith healers, snake oil salesmen, etc.). Real doctors wanted to set themselves apart from the quacks, to establish recognized standards and accreditation. They approached state legislatures to establish the first HCP acts, which limited the practice of medicine to those who had graduated from an approved medical college.

Shortly after the passage of the practice acts, D. D. Palmer, founder of chiropractic, was arrested for practicing medicine without a license. Rather than getting properly trained, his lawyer got a chiropractic practice act passed, allowing Palmer to continue treating patients without the fear of being punished. Current law hasn't changed since Palmer's time; chiropractic practice acts still define chiropractic the same as Palmer had, with about half of the states explicitly mentioning subluxations (e.g., Connecticut's law) and about half avoiding that term (e.g., North Carolina). Palmer went on to establish colleges of chiropractic. Today, there are about 15 such colleges in the U.S. None require entrance exams. Many do not require a college degree. They do not require a residency to graduate, so freshly minted chiropractors may have little or no real world experience with patients. Chiropractic colleges are "accredited" by the Council on Chiropractic Education. Chiropractic colleges can be accredited without being required to teach any science nor that what is taught is based on sound science.

When it comes to the law, accreditation is gold. Once a school is accredited, they are eligible for federal student loans, meaning that U.S. taxpayers are helping to fund chiropractic education and training. Getting practice acts passed and setting up their own accreditation has worked well for chiropractors. It is the groundwork from which they can lobby to expand their practice to primary care. And it's a model for other brands of quackery, such as naturopathy. Naturopaths are working on getting state practice laws passed, with some states, such as California, having a wide scope of practice. Like chiropractic, naturopaths have little clinical education and no residency requirements.

Ms. Bellamy urged attendees to become aware of bills in their states aimed at legitimizing medical pseudoscience. She directed people to the Society for Science-Based Medicine's Legislative Updates page, which lists bills involving CAM practices.

Panel - The Placebo Effect

Dr. Steven Novella, Jann Bellamy, Dr. David Gorski, Dr. Harriet Hall, and Dr. Mark Crislip
All five of the speakers from the morning got together for a panel discussion on placebo effects, moderated by Dr. Novella. Everyone had a slightly different way of defining placebo effects, though all agreed that when it comes to objective measures, placebos have no effect. Dr. Hall made the point that there really are two major definitions of placebo: one involves the drug being tested vs. something other than the drug (e.g. active control, a pill containing everything except the drug, a sugar pill, saline, etc.) and all of the other aspects of treatment or study. What we call placebo effects are really everything other than the treatment itself: artifacts of trial design, psychological effects of the patient-doctor interaction, etc.

The panel then went into a lively discussion of the ethics of using placebos. As Dr. Gorski noted, 60-70 years ago, medical practice was very paternalistic, and it was considered entirely acceptable to use placebos. But as medicine has evolved, and the patient-doctor interaction has become more of a partnership, it has become increasingly problematic to lie to patients. It damages the trust that should exist between a doctor and the patients they serve. Dr. Novella asked if "believing your own bullshit absolves you of the lie?"

Dr. Crislip suggested that it is a bit of a slippery slope. When a patient demands antibiotics for a viral infection, the antibiotic is, essentially, a placebo, since it will not do anything objectively for them. But you want to help; it's easy to justify the lie. Although there is nothing ethically wrong with taking advantage of placebo effects (e.g., giving a patient positive feedback), practicing placebo medicine, actually prescribing a treatment that will not work, comes with some risk, as noted by Ms. Bellamy. If a patient suffers harm as a result, they could sue the physician, though that is unlikely to happen, since most people are not willing to admit that they were duped. And even should a patient sue, CAM practitioners can fall back on a "standard of care" defense. A naturopath, for instance, could argue that what they did was fully within the standard practice of other naturopaths.

In the end, the panel concluded that education is the key. Critical thinking needs to be taught as its own skill at all levels, starting in kindergarten, and including members of the media. Everyone should know what constitutes good evidence vs. bad, as well as how to analyze a claim. That is how we can work to change the public perception.


The floor was then opened up for questions. There were a lot of great questions, ranging from placebos to how CAM studies gain ethics board approval, why so many doctors rely on CAM, how to vet a doctor to ensure they are science-based, and even contrasting the use of non-indicated antibiotics with something like homeopathy.

Science-Based Medicine Jeopardy

The day's main programming wrapped up with Dr. Crislip hosting the other speakers in a game of Jeopardy. The categories were Origins (to which Dr. Novella quipped, "The origin is never 'years of study'."), One true cause or treatment, What's the harm?, Vaccines, Numbers, and Dirt Bags. In the TV show, once the correct answer is given, contestants just move on to the next question, but in SBM Jeopardy, the panelists were encouraged to expand on the topics a bit more. It was a fun way to learn a little bit more about a wide range of issues around quackery.

George Hrab Presents: The SGU Skeptical Extravaganza of Special Significance

While the main program for the conference had ended, Friday evening had an added bit of entertainment. The last two years, this spot was filled with some improvisation. Two years ago, it was improvisational painting and music, followed by a performance by an improv group and a discussion about the neurology of improvisation. Last year it was science and pseudoscience quotes backed by improvisational music, followed by another performance by the improv group. While those shows were entertaining enough, the musical portions were a bit hit or miss. This year's extravaganza was wonderful.

George Hrab served as emcee for the crew of the Skeptics' Guide to the Universe, Steve Novella, Jay Novella, Bob Novella, and Evan Bernstein. What made the evening even more amazing was special guest, Bill Nye. In addition to being a great science advocate, Nye is an accomplished and very skilled entertainer. There was a pretty good crowd for the show, too, including members of the general public.

The Skeptical Extravaganza several different parts to it. There were several rounds of Freeze Frame, where one person had to guess the movie depicted by the frozen poses of the others. Flash debates in which two cast members faced off to argue topics that were given to them on the spot, like the U.S.S. Enterprise vs. the Millennium Falcon, or who has the best origin story: Mormonism or Scientology. The winner was chosen by audience applause. Interspersed with these were Facts that will F*** You Up and musical numbers by George Hrab.

One bit that I did have a conflicted opinion about was Skeptics on Helium, in which each of the cast inhaled some helium and then read a quote. The reason for my concern is because there are some very real consequences involved with squandering this gas. When people think of helium, they probably mostly connect it with party balloons and making your voice sound funny. What most people probably don't know is how important it is to a lot of medicine and science. If shortages occur, that can significantly drive up the price of the gas and, consequently, the price of a lot of medical procedures, like MRIs and tests like mass spectroscopy. I know that six people on stage inhaling a little helium isn't going to make a huge dent in the supply, but it's part of the blase attitude toward the helium situation. Just my little rant about something that really deserves greater awareness.

To finish off the night, folks headed off to Connolly's Pub on 45th Street. If the talks during the day aren't your thing, the evenings of Drinking Skeptically are a good chance to socialize with some of the other conference-goers. I met several new people there, as well as some others that I only knew online. Overall, it was a nice end to a full day.

1 comment:

  1. Thanks for the link to the video with Sandy Nette, the woman who got a stroke from chiropractic neck manipulation.
    There's a playlist of 4 videos at which is much worth looking at.
    Her husband talks in the first 3 videos.
    Chiropractic neck manipulation a horrific practice.
    I was horrified awhile ago to see an ad by a chiropractic pediatric association, promoting neck manipulation for *babies*. When they have trouble breastfeeding and their neck seems to be stiff.
    I posted about this in a "skeptic" group; and immediately I was in an argument with a very abrasive chiropractor.
    I found there's no research on how dangerous this practice is when done to infants.
    Possibly the research about the dangers of chiropractic neck manipulation on adults, doesn't apply to babies. Are a baby's neck arteries more vulnerable than an adult's? Less vulnerable?
    It seems like the skeptics are underfunded and the chiropractors have the time and money to go around writing papers to "prove" that neck manipulation is safe or at least that accidents are very rare, or that if there is a stroke, it isn't their fault.


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