Sunday, December 18, 2016


Friday, the semester ended for me, and for the Class of 2016--our accelerated "second degree" nursing students. In 16 months 27 people from backgrounds in biology, English literature, accounting, political science, and other fields managed to master the enormous amount of complex material and clinical skills to become Registered Nurses.

Pinning is a nursing tradition. At the end of nursing school, many programs hold a ceremony to celebrate the students' rite of passage from unschooled novices to competent nurses. Ceremonies vary in their content and style, but most contain a group recitation of the Nightingale Pledge. The original pledge spoke to the Victorian mores of the time: probity and forbearance from "mischief", faithfulness and purity were emphasized, no doubt reflecting the way society thought women should behave. The nurses should "aid the physician in his work" (emphasis mine), reflecting the place of both women and nurses with respect to both men and physicians at the time (from Lystra Gretter's 1893 version of the pledge).

The Gretter pledge also had the graduates pledging before God, which of course makes sense in light of the time. Most people were nominally of the Judeo-Christian traditions that underpinned European and American societies, and the then- and formerly-colonial regions to which they had spread, such as South America and much of Africa.

I do prefer more contemporary versions--even though they don't have the long tradition--because they recognize that not everyone believes in "God", much less a one-size-fits-all god, and because although part of what we do is to aid physicians, we also aid other professions.

Moreover, in "aiding" other professions--including medicine--to do their work, we more often than not coordinate everyone's efforts, physicians included. That doesn't even get into our own discipline's body of knowledge about health, healing, and humanity that form the core of Nursing as a medical art both of and distinctly different from Medicine. It is the similarity of our work to the work of Medicine that makes Nursing amplify the healing art. And yet it is our distinctiveness that also serves as a counterpoise to Medicine. One can routinely observe this in the clinic: The nurse humanizes the fraught work of the medical man. Medicine, by its very nature, can become the grotesque creator of monsters artfully depicted by Mary Shelly's Dr. Frankenstein. Nursing, by its very nature, acts as Medicine's conscience.

The importance of this emerges during training, and we instructors emphasize this role as counterpoise to the physician. But we're partners too. We observe, report, and execute the regimen. They have the deep knowledge of anatomy, physiology, and medicines that solve the medical problems. They save lives, but then so do we, both in their absence as we monitor patients through dark nights, but also in their presence, when hubris, fatigue, or just plain orneriness threaten the poor fellow lying in that hospital bed.

The Factory, which I have written about here before, has created a new alliance between Nursing and Medicine, in my view. Once, we were as much at odds as we were allied, nurses and doctors. That's still true to a great extent, and as I have argued here, not an altogether bad thing. But The Factory has emerged as a new player, a new force with its own agenda. Some agents of The Factory are explicitly for profit. The looming harm of this is, to me, obvious. It's less obvious when examining the non-profit agents of The Factory. Who is making the money? What's the real goal? Is it to make the system efficient and humane? Or is it to enrich the operators of the enterprise?

I gave the closing remarks at our pinning ceremony on Friday. I wanted to keep things short and light, but I could also see the potential in the room, and urged the students to make things better. That's really hard when you're a nurse: the organization often pits your own good morals against prerogatives that seem anything but humane and compassionate. It will be hard for them. I hope we prepared them adequately for that struggle in the short time we had to prepare them.

Sunday, December 4, 2016

What is Science, Really?

This past week I've been getting pop-ups asking for donations when I go to Wikipedia. The last couple of years I've clicked on the Donate box and sent them a few bucks. I figured it's a community resource of sorts, non-profit and volunteer-run. Why not?

This past year I went to Wikipedia at one point to read the entry on homeopathy. It was really long, and it was heavily slanted toward the notion that homeopathy is a pseudoscience, and that the bases of homeopathy are founded on corrupt, disproven principles (such as "molecular memory"). The preponderance of primary research studies cited as "evidence" of homeopathy's lack of efficacy are cherry-picked from the available body of data.

I couldn't edit the page because it is "locked" to prevent "vandalism." I took a stab at trying to learn how I could become a part of the accepted body of editors, but it proved to be a bit of a chore so I let it go.

Recently I took another stab at it. I have a bit of time now that the semester is winding down. I ranged across the hyperlinks that discuss the various things that would bear on my task: the different locking "levels", how to become an editor of locked pages, and the categories of articles displayed on Wikipedia. I clicked on a link that discussed "pseudoscience" in the context of editing, I saw a long list of things that the community editors think of as "false science", including homeopathy, osteopathic manipulative therapy (OMT), and chiropractic (all of which have evolved as clinical practices, and all of which have empirical data to suggest their efficacy--however chiropractic and OMT are beyond the scope of today's article).

As I read further, clicking over to the entries discussed in the previous paragraph as well as others, I began to discern a pattern. Now I will grant that many of the things on their list are historical fancies (e.g., "ancient astronauts" or "moon landing conspiracy theories") or metaphysicial pursuits (astrology, creationism, channeling) that lack hard evidence and/or are not otherwise subject to Karl Popper's scientific falsifiability. The list is also very long and includes things that may lack hard evidentiary support, nevertheless may offer plausible hypotheses that could one day explain certain natural phenomena.

Pseudoscience is, I suppose, a real thing. It's reasonable to argue that some domains of theory and practice ought to be best left to the believers, with the hope that good things will follow. For example, my wife, a musician, has been studying sound healing. Part of this has been to reintroduce her to "chakras"--which are presumed to be seven loci of energy flow in the human body. Often depicted as foci of colored energy, there are various systems of chakra patterns that stem form various ancient and modern beliefs.

She knows that no one has "proven" the existence of these chakras, and yet she feels their presence when she gets work from people doing Reiki, or when she works with her singing bowls. Does this make it pseudoscience? Metaphysics? Or is it simply a framework for integrating intellect and spirituality that applies to specific moments posed by the subject of the work?

I occasionally perform Therapeutic Touch on patients. When I do, it's coincidental to the rest of the more medical purpose of the visit. I don't charge extra money for it. I don't know if something is happening, but I feel it, and often the patients do as well. I don't claim to know what's happening or why people feel better afterward, and I can accept that the effects may stem wholly from mindfulness, quiet, and taking a few minutes to reduce the general emotional arousal in the room.

It might also be mysterious energy. Who knows?

So then why must the critics scornfully call this "false" science? Scorn should be reserved for mendacious con-men whose only aim is to separate fools from their money. Scorn should be reserved for those who would impose their metaphysical peculiarities on the rest of us in a civil society. Scorn should not be aimed at earnest people who mean well and largely cause no harm. Ask their patients: if they feel wronged, they will say so. Mostly, they feel cared for. (I know because I bother to ask.)

Carl Sagan correctly acknowledged that for something to be subject to proof, it must exist, and there must be some way of verifying or falsifying the thing's existence. Philosopher Paul Feyeraband suggested that scientific "anarchism"--freeing our science from the constraints imposed by socially-mediated sets of rules--would free our minds to explore. Some things will pan out. Others won't. Philosopher Larry Laudan argues that "pseudoscience" has no meaning, and is mainly a term of emotion. To this I can testify: I've had plenty of conversations with smart but unimaginative blow-hards who like to spew bile and spittle against people practicing arts that may seem to their practitioners as scientific, and seem to the spewer as "pseudoscientific claptrap!"

I think it's a bunch of self-righteous nonsense.

I've practiced homeopathy for 20 years. Save for the first few, in which I felt the rush of hope and light of the "true believer", I've been a skeptic of sorts. I've kept up with the literature surrounding homeopathy and I've found myself alternately pleased and despondent about it. Klaus Linde's 1997 meta-analysis of clinical trials of homeopathy hesitantly suggested that the technique's effects could not be accounted for by the placebo effect. Translated: Yikes, this weird thing we can't explain may actually work!

British researcher Edzard Ernst has made it his life's work to debunk homeopathy (after briefly training in it) and in a 2002 meta-analysis concluded that homeopathy doesn't work. Lancet published an editorial in 2005, "The End of Homeopathy", based on the work of Aijing Shang's team, in which they compared 110 trials of homeopathy and 110 matched trials of regular medicine. The team claimed that homeopathy performed no better than placebo (and interestingly, that regular medicine barely did!).

I have to say that this had left me feeling for a while like maybe I've been barking up the wrong tree. And if I really am a scientist, I have to admit that maybe it's time to hang up my repertory. I can live with that. (That's what a scientist does.)

I dug deeper. Recently, I completed a study in my own practice, a simple chart review. I'll withhold the specific results, pending publication. But it's enough to say that the results are intriguing. I'm not sure if they are the result of homeopathy, or my awesome bedside manner, but it is unlikely the results are solely caused by chance. In preparing the article I dived into the literature again.

Robert Mathie is a homeopath and researcher--so he has a point of view--but I found his team's 2014 meta-analysis of homeopathy to be enlightening. He concludes that homeopathy appears to work. So how is it that some meta-analytic studies find it does work, and others find it doesn't? The answer appears to lie in methodology, and methodology appears to be driven in part by one's point of view.

I found an article by Robert Hahn, an anesthesiologist with Linkoping University in Sweden. This guy isn't a homeopath, and he hasn't made his name as a crusader against "psuedoscience." He's just someone with a curious, open and discerning mind. His literature review of the studies touted by mainstream medicine as evidence of the ineffectiveness of homeopathy found that authors were guilty of a number of methodological malfeasances. He states:

Clinical trials of homeopathic remedies show that they are most often superior to placebo. Researchers claiming the opposite rely on extensive invalidation of studies, adoption of virtual data, or on inappropriate statistical methods...One way to reduce future emotional-driven distortion of evidence by investigators and skeptics would be to separate the evidence-seeking process from the formulation of clinical guidelines more clearly. (1)

And remember, this was before Mathie's group published their analysis in 2014.

I might suggest to those who would apply the label pseudoscience without careful pause, that they themselves are "pseudoskeptics." Pseudoskepticism is a habit that substitutes an emotional certainty of disbelief for real skepticism. Real skepticism admits the tenuousness of scientific theory, withholds certainty, and leaves emotion where it belongs--outside the lab. A real skeptic would admit that homeopathy doesn't fit in with our current physical, chemical, and medical theories, but would admit that both the clinical evidence and empirical evidence do show that something is happening. Actual clinical use of homeopathy is a choice between deciding to wait until more information is forthcoming, or plowing ahead with what we do know, aiming for as much care and safety as we can.

Part of what makes the skeptics--or, er, the pseudoskeptics--crazy, is this issue of care and safety. I'll be the first to admit that there are a bunch of people out there utilizing this method in unsafe, unethical ways (see my previous article). But medicine itself relies on clinical experimentation. Without it, patients will suffer and die while science patiently--and slowly--advances. Clinical experimentation with alternative therapies can be performed ethically (2)...and in the process, maybe we will help a few more folks than we would have otherwise. The results may puzzle us, but should inspire us to investigate further.

1. Hahn, R.G. (2013). Homeopathy: meta-analysis of pooled clinical data. Forschende Komplementarmedizin, 2013;20:376–381 doi: 10.1159/000355916.

2. Adams, K.E., Cohen, M.H., Eisenberg, D., & Jonsen, A.R. (2002). Ethical considerations of complementary and alternative medical therapies in conventional medical settings. Annals of Internal Medicine, 137:660-664.