Sunday, 3 May 2015

A Shiny New Blog and Web Address

Hello all,

Just to let you know that I've moved over to another blog at another address. The new one is miles prettier. I've moved all of my old posts over and will be posting new ones over there only, so make sure that you change your bookmarks and all of that kind of malarkey.

I'm going to look into trying to sort out automatic redirection, but in the meantime, make sure you head on over to:


Tuesday, 28 April 2015

The beauty of disagreement

If this skepticism lark has taught me anything, its that disagreeing is a beautiful thing. Disagreeing with someone is a hard thing to do, in any context. Yet as humans, health care professionals, and as skeptics, its one of our keenest tools. Its only by being able to step into disagreement that we can understand our topic, our audience, and hopefully steer hearts and minds away from those willing to mislead.

I recently attended a panel about daring to disagree, which mainly focused on religious debates over Twitter and the like. I'm guilty of wiling away hours of my life arguing with homeopaths over twitter, and I'm often asked why, as I'm never going to change their minds. The short, and most noble answer is that someone undecided might spectate, and I might be able to make some impact into how they think about the subject. The more self-serving version is that its good practice to hone my skills in identifying fallacies and flaws, finding workarounds and ways of wording things, and to understand an argument in advance of the next time. In these types of arguments, the people who you are speaking to are removed from yourself, perhaps not anonymous as such but they tend to be used to arguing. Their position is usually on the defensive in the first place because their chosen subject has usually been the butt of skeptical inquiry for years.

But what of those closer to home? Sticking out heads up above the parapet in other situations is one of the hardest things in life to do. Most of us instinctively see disagreement as a threat and a personal attack, and we react accordingly. Even now, despite all I've learnt about constructing arguments and debates, with all of this practice, I certainly still get physical reactions when someone disagrees with me. My heart will pound, my mouth with become dry, and I'll want to curl up in fear because my body and brain immediately leap to the conclusion that no one likes me, that I'm so insignificant that I must automatically be wrong. I'm thankful to skepticism in that I'm able to take a deep breath and overcome those initial few moments, then can try to reassess my position. Am I actually right, but there are some good points to take away from the other stance? Or actually, is my reasoning flawed? In which case, why? Where could I have found more information, what is the other person bringing to it? Whichever way it goes, I, and the other person, end up learning more. Ultimately, we're not here to be right or wrong- we're hear to learn more, and that's the important bit.

Problems arise though because often our instincts take hold. I can't describe the number of times its all gone tits up. I can spend ages agonising over whether or not to disagree. Once I've decided to do so, I write and rewrite my argument so that it is as objective as possible, structured clearly, evidence based etc., only to have the response be “Eurgh why are you being so mean?! I thought we were friends!” or similar. I've tried all sorts of ways to word things, and I haven't quite come up with an answer on how best to avoid this response. Its not just Facebook etc. where this is a problem- we all hear in the news about irrevocable breakdowns in the doctor-patient relationship (Ashya King, as an example). We've all encountered the patient at the pharmacy counter who believes a random person waiting in the queue over our own expert advice. No one learns anything from these sort of exchanges, and that's a real missed opportunity.

So the question is, how do we go about promoting disagreement as a positive thing that we all need in our lives? How do we turn the tables on the thousands of years of evolution that make us shut down arguments as soon as they begin? Well I think the answer has to initially come from example. I believe the skeptical movement is extremely well placed to start this tidal change in thought, but we all have to practise the heck out of it every single day if we're ever going to get anywhere. We have to start being known synonymously as folk who are really, really good at disagreeing respectfully, and that has to start from within. Its clear that the skeptical community in the UK and beyond occasionally falls short in this regard, and that's a real shame as it appears to be driving good people away.

We need to recognise that we might agree with someone on one thing, but not the other. We can't see a person as synonymous with one of their opinions, and put people in good or bad boxes based on that. We shouldn't be labelling people as anti-this, or anti-that, and then refusing to engage further. We should be experts at digging deeper than that, looking behind the headlines to search for shared humanity underneath. We need to lead the way in disagreeing without bullying, and we should never, ever let up on that. We put ourselves in a position that could so easily be mashed up together with bullying by the general population when we dare to disagree, and we need to be relentlessly exemplary in our behaviour to prove that we aren't. We need to be the type of people who, even if faced with a mutant hybrid of Nigel Farage and Piers Morgan, would manage to keep their cool and be polite.

But then again, feel free to disagree ;)


Friday, 20 March 2015

Allergy Relievers: Red Light Nonsense

Its just about coming into allergy season again, so today I am turning my attention to a product I’ve seen for sale in a few pharmacies I’ve locumed at of late: The Allergy Reliever Device. These things are sold under some pharmacy chain’s own names, or under brand names like Kinetik.

It’s yet another medical device. These things seem to be hitting the pharmacy shelves more and more often these days, giving them a level of respectability which personally I don’t think they deserve. At least this device makes it clear that it is a device though, unlike things like Prevalin which pretend to be real medicine.

According to Kinetik, it uses “red light therapy to suppress the cells that release histamine, thereby relieving the symptoms of hayfever and allergic rhinitis.

So, essentially shoving some Christmas tree lights up your nose then. Well I must admit that’s a new one on me. It’s pretty hard to sniff out (geddit?) the theory behind this one too.  The manufacturers of these things don’t give any explanation as to why red light would suppress mast cells, and several Google searches later I’m none the wiser. I have managed to dig out one published paper in rats, where the authors seem to be suggesting that red light changes the redox state of cells, which might cause some changes within the cell. Even these others say that they’re not quite sure what’s happening though, and that further investigation is required.

Armed with a few unsuccessful Google Searches, I delved into the medical literature. I tried every which way I could think of to search for evidence that this thing works, but ended up drawing a total blank. I think this may well be the least successful search for evidence I’ve done so far, and that’s saying something. Even the manufacturers can’t be bothered with listing any sources instead they go wild with the clipart, giving us a Generic Smiley White Coated Person and Happy Photostock Chef alongside some very random recipes and general lifestyle advice.

And it looks like this thing really isn't very pleasant or practical to use. You're supposed to shove the probes up your schnozz as far as you comfortably can, then keep them there for three minutes. Not the most dignified of poses. And you're supposed to do this three or four times a day. That's a lot of inconvenience. Seems like prime Use Once Then Put In A Dark Cupboard territory for me, especially since taking a one a day antihistamine tablet is no hassle at all. 

In short, I wouldn’t waste your money. There’s no basis to these things, and it saddens me that they are not only being sold in pharmacies, but are being sold under pharmacy brand names. The more we associated our profession with such nonsense, the less trustworthy we become to other healthcare professionals and patients alike.


Friday, 13 March 2015

"I do my own research"

Something that I see a lot in on-line debates about alternative medicine is phrases like “I did my own research” or “people should be allowed to do their own research and make their own decisions”

However, I don’t think that the vast majority of people are able to do their own research. Now, that’s probably a pretty unpopular opinion. It’s patronising, paternalistic, and it flies in the face of patient choice. Who am I to question the intelligence and abilities of other people? Why do I think I'm so clever compared to anyone else out there? Allow me to explain myself.

I've been a pharmacist for a very long time now. From uni, through pre-reg, to my own revision at work, I've been taught critical appraisal skills. Yet to this day, it’s something that I actually find really hard work. It’s a skill that requires continual honing, and every time I use it I feel like I am fighting with my brain.

Even in the last two weeks, I've been revisiting my critical appraisal skills to make sure they are up to date. I've done some in-house work, three on-line courses, and a one to one training session. Yet I still find myself sat here at my desk for several hours, if not days, looking over the same study with a furrowed brow, desperately trying to make the numbers and statistics tell me their story.

There’s hazard ratios, odds ratios, confidence intervals, numbers needed to treat, event rates, absolute risks and other confuddling terms to deal with. I naturally struggle with numbers at the best of times; like most people, I much prefer narratives. That means that I have to constantly argue with myself to keep looking at the results page, rather than just flicking to the discussion. Becasue if I did that, I'd be relying on what the authors, with all of their possible biases and agendas, say their numbers say. Then, when I eventually manage to squeeze the swimming mass of figures into some sort of order in my head, I find out that these numbers aren't the full story, and I need to dig even deeper into other analyses of the same figures to find out what’s really going on.*  

A quick and very simplistic visualisation of all the layers of interpretation that might lead to information found on your common or garden health information website. That's a whole lot of bias. 
I am truly terrible at MS paint, but you get the idea. 
What a typical EMBASE search looks like. This is for a new drug with few synonyms so its a fairly straightforward one. Others can have forty odd lines of searches. 

It’s not a pleasant task by any stretch of the imagination. It really does feel like a mental marathon. I often question whether I am even up to the task- I can end up feeling stupid, and confused. But in order to really figure out whether or not a drug works I need to strip away all the levels of other peoples’ interpretation and start from scratch, with the cold, hard, impersonal numbers. That way I can build my own narrative, uninfluenced by what the study’s authors or sponsors want me to think, by what newspapers want me to believe, by what campaigners want me to know. The only way to know the truth is to start right at the bottom, in a dark dank pit of statistics, then to slowly start building yourself a ladder until you emerge, blinking, into the pleasant knowledge that you've worked out what on earth is going on.

This sort of raw data is not only extremely hard to deal with once it’s in front of you, but its also pretty difficult to come by. Finding it in the first place includes searching multiple medical databases- and these things aren't just a quick free text search like you would do on Google. Constructing a search can in itself take an hour or so, and then you have to trawl through the results to decide which are relevant to what you are specifically looking for. For me, most of the time, a question is structured like this:

What is the evidence that [drug/ group of drugs] works for [disease] in [patient group]?
So, in my poorly drawn Venn diagram below, I need to find those holy grail papers that reside in the pink area:

Some of these papers might be pay-walled, so it’ll take me a week or so to get my hands on them. Some of them might initially look promising, but once you start to dig down into the figures you see that there might actually be problems with how they were undertaken or reported, or they might turn out to not quite fit in some way- perhaps the dose they used in the trial is different to the licensed dose in the UK, or the people enrolled into the trial don’t quite fit the population you want to know about, or perhaps the trial just didn't recruit enough people so any results from it are invalidated.

I've been doing this job for years, and I really do still struggle with all of this stuff. That’s not because I'm poor at my job, or because I'm stupid, or because I haven’t put the effort in to understand it. It’s because, when it comes down to it, this stuff is really bloody hard. It’s time-consuming, boring, and unintuitive.

People might well feel like they've done their own research. They might spend several hours digging about on the internet and feel empowered by any decisions that they make. But what they don’t realise is that what they've been researching isn't just the information- it’s the information with many, many layers of interpretation (and therefore bias) added. For a choice to be truly informed, you need to go right back to the start, to those terrifying tables of numbers and statistics. That’s simply not realistic for the majority of people.

Far better, then, to learn how to decide on whose interpretation you’re going to rely on. Will it be those that take the media reports at face value, or who have an agenda or a product to sell you? Or will you go with those that have years of training in how to pull apart complicated data and disseminate it in understandable ways?


*I thought I’d give you a quick real life example here, but I thought it best to asterisk it because I've probably bored you enough already. I'm currently looking at a drug called edoxaban and its use in reducing the risk of stroke in patients with atrial fibrillation. It’s the newest in a series of  novel oral anticoagulant drug- they’re supposedly like warfarin, but less faffy. So I find and look at the main trial, and spend days unpicking the stats. It looks like both strengths used in the trial are no worse than warfarin, and the higher dose might even be a little better. Great, right?

Well, that’s not quite the end of the story. Because it turns out- and this isn't reported in the trial at all, but instead is contained in the FDA’s briefing document- that in people with fully working kidneys, edoxaban is actually worse than plain old warfarin. In people whose kidney’s aren't quite at full capacity though, it might work better than warfarin. So the overall trial results are kind of skewed, and if we didn't dig deeper, we might have been giving a whole group of people a more expensive drug with worse outcomes than warfarin.