In toto et summo

October 31, 2010
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The fallacies of logic and limitation of our cognitive worldI had fun over the past few weeks. I have fun every week but these weeks had been particularly interesting. I had a few debates in Blogland and have (finally) come to understand that I am just going into repeat mode now. Same sceptics, making the same comments on the same sites. Ground Hog day. And I like it.

Richard and a few other posters were encouraging me to just give in and don’t try to save the lost causes. Thing is… I am slightly autistic, I think, and actually really like Ground Hog days. I am also slightly OCD and have this mannerism of being overtly particular and precious about phrasology, context and interpretation. It really helps when argueing a point in Blogland. The inhabitants of this country seem to have similar things wrong with them. Zeno’s blog is our Mecca. You do three tours and you’re reaching the third degree in the order of Onan. (it’s a joke – my wife often reminds me that jokes are supposed to be funny to be jokes, but what the heck! Screw the rules) Then they know your name and start making assumptions about you. I have had much fun helping people realise that they were really just assumption-making machines. Thank you to all people who could be arsed to set up a website.

Zeno the Warrior Prince and his Penpals have made a very good point in the ASA adjudication vs the GCC game and has hopefully taught us all a good lesson: don’t talk shit. The rest of them though are making less and less and less (and less) sense. It’s not their fault, they are just failing to see that the fun really only lies in making sure that people don’t talk shit. It’s not enough fun for them though, they think “there has to be more to life than this“. Bowing their heads, quoting completely irrelevant issues as if they carry any weight: (squeaky comedy voice) “Ooh, the Fairy Grumpfather says you have three testicles, and you will have to provide a publicly tested Randomised Clinical trial and prove conclusively that the number three is greater than two.” Just because the Fairy Grumpfather said so. It’s all a bit biblical to me. This in fact reminded me of Darwin and more specifically the problems he had with getting acceptance for what in my view is the greatest discovery of thought in the history of humanity. Dawkins cleverly wrote about this in “The blind watchmaker”. To paraphrase: Yes, sometimes things really are just that simple and there is no need to make up more complex theories just to soothe your need for meaning.

I am a big fan of Dawkins and have contributed signifcantly to his retirement fund. He talks about the “holy tea-pot in orbit around a far way planet” in one of his books. This refers to the concept of belief and the view point that the onus of proof lies with the person(s) making the statement. I don’t disagree with him on that, but although I think that religion is in a bracket of its own (have it if you want as long as you don’t judge me by it or harm me/my family in consequence of it)  I think that the same rhetoric cannot always be applied in the way that some infer it can be (i.e. ridiculing things that don’t have scientific evidence as “religious” or “faith-based”-with a further implication that because it is faith-based it must be nonsense, which in fact is a solipsism of the highest degree). In consequence; the rhetoric proposed by some of the people in Blogland has to be exposed for what it occasionally is: tiddle. It is complete nonsense to argue that you cannot make a statement just because there is no RCT evidence available. Evidence is about testing plausibility. That said it is true that good plausibility is not evidence, but regardless of what it isn’t (proof) it still is good plausibility… Good plausibility is more likely to have good evidence supporting it (by virtue of the test being more obvious with increasing levels of plausibility) but lacking in evidence to support good plausibility does not in itself mean proof of implausibility. What it does mean is that in the UK, under the rules of the ASA you can’t say it unless it has positive evidence to support it. This has nothing to do with science or even logic. It has to do only with the rules of the ASA. Which some could argue are a bit flawed really, but to make it better would require an institution like the ASA to make judgement which then involves experts. Some of whom we all know are really not expert at all, some of whom have not even been able to answer some of the most basic questions like: “what should a patient who has tried other treatment options and failed do?”

The thing that some boys and girls are forgetting when playing in the field of logic is that the part of what makes plausible theory more or less obviously testable are the complexity of the theory and the technological requirements of the test. It is understandable that they are missing that point as complexity is innately associated to implausibility as per the lex parsimoniae also known as Occam’s razor or Keep It Simple you bleedin’ Dimwit. Hand in hand with this merciful indication towards an affinity to frugality however lies also the problem for those who are innately perturbed by complexity: father William of Ockham did make one very important addition to his law: “entities must not be multiplied beyond necessity” (entia non sunt multiplicanda praeter necessitatem). Ah, bummer… what constitutes necessity in any given condition? This is where I really wished people read a little more, skeptics and chiropractors alike as talking drivel is not the prerogative of  either but an abundantly available activity in both… and there are some really good books which will reduce dramatically the amount of drivel.  Back to the issue of necessity for complexity:

I contend that the field of healthcare has been over-simplified (and this is not judgement of those who work within it, but rather an acknowledgement of the challenges faced by people who are supposed to be doing one thing but being asked to do another as an unfortunate by-product of a lack of understanding and appreciation of those stood outside it and observing making de-contextualised judgement). I contend that the “great discoveries of the 19th and 20th centuries” were to today’s measures basic and  that the needs which are currently emerging are requiring a complete rethink of the foundational principles upon which the healthcare of the near future will be based. This is in no way to be understood as derogatory to the feats of science and the great pioneers and discoverers of that era. it is by no means an omission of the role it has played in reducing illness, disease and death. It is in no way a failure to recognise that the healthcare of the 20th century could be attributed with adding a significant number of years to life expectancy. It is just a recognition of process. Only eating fresh kill did much good, so did burying the dead outside of city-walls, so did washing hands and instruments, so did pasteurisation, so did inoculation, so do international policies to contain pandemics. And the process at each stage was encapsulated by an increasingly greater complexity and our respective levels of comfort with this complexity. The first (in the preceding examples) was about being repulsed by the smell of rotting carcass, virtue of survival of our ancestors that were repulsed versus their siblings who weren’t and would die. Fear of the dark spirits of the dead roaming the city and bringing death to their family and neighbours was part of the second. Heavily assisted by our human brain’s capacity for pattern recognition we logically deducted that the spirits would leave the living alone if they were buried outside city walls. The third  was almost pure logic and deduction and pattern recognition on experiences. As rules emerged, were agreed upon, and note-taking became part of standards the fourth and fifth would almost evidently emerge and the sixth would  only become reality when computing power and communication tools became so powerful that world-wide networks became possible.

This is process. What else is process is that we come to understand nuances, we refine. The same tool can be used for multiple ends and highly similar or even identical ends may require completely different tools. This is a new level of complexity for which there is an emerging market in health care. Why and where is this market? That market resides in those for whom being treated with the same tools is not eliciting the expected outcome. The degree to which the classification and nomenclature of the nature of their similarity to other presenting cases is not refined enough. It  has always been like that, whether it was the smell of a rotting carcass or the observation that certain wards had significantly fewer deaths. Process of refinement and discretion, a lack of which was usually paid for with death. So are we done dying now? No, not quite but there is a growing population, particularly in the West that will be getting really quite old and who want to proactively consider their quality of life in old-age as they now have that very real luxury. Chiropractic theory was so far ahead of its time that (and this is pure conjecture on my behalf) they themselves did not realise the full meaning of it at its inception. They were looking ( I think) at systems to improve function. Systems to improve well-being as  a result of improved function. Systems to improve quality of life and battle dis-ease (NOT “disease” as some dimwits keep on getting wrong). Now that sickness care has dealt with so much of our sickness there is an emerging market of taking wellness and quality of life seriously. After all, what’s the point of looking at quality of life if there is no life? There are also more and more people recognising that this would be a valuable commodity. In an analysis of emerging markets done for private equity firms…. wellness is the third largest emerging market. Not small fry. But that doesn’t mean that chiropractic represents a solid offer to this market by any means. I just think it does. And yes, the form in which I think it does that has relatively little to do with what a lot of these so-called skeptics think chiropractic is about.

The next argument I have to then contend with is “Why don’t you do the research then?” Well, thing is, it’s not that easy now is it? I am working on it but it really, really is not that easy. There are aspects of the chiropractic theory which can be tested relatively easily, but in isolation their conclusions really would not come to mean anything of any value regardless of their conclusion (good or bad). And that is the thing you see, chiropractic theory (the real chiropractic theory, not the raped and abused version of it that quackwatch, Sam Homola, Blue Wode et al are promoting to be representative of chiropractic theory) is not one that allows you to chop it up in pieces and look at the parts and then assume that the actual total is the theoretical sum of its parts. This doesn’t mean it can’t be done. It just means it’s a pain because we are researching a scope of practice and not the “bits” of a “chopped in bits”-procedure. The other thing (and this further underlines the relative unfairness in the method of the ASA-but I am not complaining: standards have to be set and I appreciate that this is better than letting people just talk nonsense ad infinitum) is that the funding of research is directly proportionate for treatment where there is a party which stands to gain significantly from the outcome (I didn’t make that up) and funnily enough results of RCT’s are more likely to be positive when the funding party stands to gain from the RCT (I didn’t make that up either). On the safety and complexity side of things, it should also be noted that assessing rare or infrequent events would require RCT’s with extremely large sample groups and it is therefore considered to be best done by observational studies. Some people will think I am talking about strokes… I am not, I am talking about finding out the parameters that define those cases that seem to respond to a treatment (say asthma to spinal manipulative care) in very specific circumstances. I am talking about recognising that the diagnostic label is the start. Defining the causal factors as part of the diagnostic process is where it’s at! A fracture is a fracture? No, an osteoporotic fracture is a very different story to a traumatic fracture. An osteoporotic fracture in an elderly lady or in a young teenager are a very different thing yet again. Nuance and refinement…

Alternatives to RCT evaluations are now being discussed in healthcare for situations where randomisation is impractical or unethical and the likes of Blue Wode who have read enough to know a little but not enough to know they know nothing really do need to be doing a bit more homework if they don’t want to keep on looking like total idiots. The suitability of RCT-process has been called into question many a time and the process of insurers or government agencies placing their judgement on these RCT’s should be replaced by a balanced consideration of clinical, ethical and economic issues. And that is just the thoracic surgeons speaking…

After all; a square is a square and a circle is a circle. If you’re going to agree calling a square a circle just because some idiots are saying it over and over again, then you really need to reevaluate your role and function in life… I have asked chiropractors before if they could flaw my understanding/interpretation of chiropractic theory on amongst others this blog. No-one did or could, but in the event someone can tell me that it is I who calls a square a circle, please have mercy and let me know as soon as possible. I don’t want to live in ignorance any longer!

Many kind regard

This is, after all, only just beginning…

Stefaan

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  • John

    “skeptics have nothing but patient safety and the public interest at heart”

    Last week I posted on SBs site research indicating the risks of coffee drinking and asked what he did to warn or protect his customers

    Transient Stroke risk
    http://www.ncbi.nlm.nih.gov/pubmed/20881275

    Increased Fetal Death
    http://www.ncbi.nlm.nih.gov/pubmed/1620780

    “exceptionally even life-threatening side effects”
    http://www.ncbi.nlm.nih.gov/pubmed/10914439

    Mysteriously this post has vanished… He is all for open & honest debate

  • Eugene Pearce

    Nice article lost me in the middle.

    At the end of the day all we want is a level playing field across the entire healthcare community. Drugs carry a greater potential risk therefore the standard of evidence need to be higher in my opinion (large scale double blinded RCT’s) than for the bulk of what an average Chiropractor, Physiotherapist, or Osteopath does.

    The thing is, it is reasonable that biologically plausible techniques where the intervention is relatively safe should not need the same burden of proof as something that is biologically implausable. For example, SOT used to treat say autism, a biological mechanism is unclear therefore level of proof needs to be high. Manipulation of a joint in the neck for say migraine carries an hypothetical, biologically plausible, risk of stroke, so either a high standard of proof (statistical probablity) is needed for safety (Haldeman Study), or clear clinical benefit needs to be demonstrated, (Bronfort? although undertaken by him, and reviewed by him as Good evidence, Conflict of Interests who knows?) The fact is any risk devided by zero is a very high number. Manipulation of a thoracic vertebra for thoracic pain is low risk in a healthy individual and therefore burden of proof could be left at biological plausibilty and outcome measures.

    With regard to Wellness, I would like you to elaborate on “But that doesn’t mean that chiropractic represents a solid offer to this market by any means. I just think it does. And yes, the form in which I think it does that has relatively little to do with what a lot of these so-called skeptics think chiropractic is about”. I just dont have a handle on “wellness” at all.

    See the numbers of patients with musculosketal disorders, rates of back pain, and conditions we have some evidence for, and reasonable biological plausibilty. Why the hell arent we concentrating on that instead of muddying the water with a wellness concept that we share with, health food shops, gyms, crystal healers, spiritual guides, Reike, hypnotherapy, beauty therapy, and a myriad of other namby pamby interventions that jump on the “wellness” bandwagon.

    What this profession does not need is more “be a better you, run an ethical practice, whilst being on the golf course” seminars. Usually at an airport hotel near you because the colleges wont touch them.

    I dont think it helps us knocking what medicine is doing wrong like “fed up” has done because the us and them thing is really petty. Being introspective and taking a long look at what we do and what we can potentially offer, with open debate is precisely wahts needed. Its why this site is so useful.

  • http://spinaljoint.com Richard Lanigan

    The interesting thing about this is that people complained and the regulator ignored most of the complaints. Another health regulator not fit for purpose.

  • fed up

    If the skeptics have nothing but patient safety and the public interest at heart, maybe they should put their efforts into something important and have a look into the EBM at this place.

    Inquiry into neglect at hospitals begins

    “Appalling standards put patients at risk and between 400 and 1,200 more people died than would have been expected in a three-year period from 2005 to 2008.”

  • Ex McStudent

    Tried to contact you, tonight’s message bounced back…..

  • http://www.chiropractorswarwick.co.uk Stefaan Vossen

    Just posted a response to the blog. It is interesting how brown can look like pink when one spends too much time up one’s own derriere…
    Hope you’re well Richard and thanks for the kind words. Nice work. These time they are a-changing. Someone said that once. Or twice.
    Stefaan

  • http://spinaljoint.com Richard Lanigan

    Steffan, you have the ability to go much deeper than I can. I think skeptics ,chiropractors scientists spend too much time with like minded people and loose the ability to think critically about the assumptions they make about life, health etc.

    Have you seen this latest posting by Andy Lewis http://www.quackometer.net/blog/2010/11/chiropractors-at-war-with-their-regulator-the-gcc.html Its one of the first times I have read a skeptic blogging about chiropractic and I could see where he was coming from. This posting articulates reasonably well where the factions within the profession have taken us and why its important for the chiropractic profession to work together and articulate clearly what we do to the general public.

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