I recently had the pleasantly unpleasant experience of being cursed on the internet. Now this is not an unusual event. As we all now know, the anonymity of the internet brings out some of the least salutary features of human character. Internet road rage, we should call it, this freedom from civility that emerges from being unknown. Unpleasant then, but pleasant too. For most writers, calumny is preferable to neglect. 

The immediate occasion for such passion was a humble online article on statistics, of all things, specifically a defense of science, or, in modern lingo, evidence-based medicine (based on my recent book on applying statistics in the practice of the mental health professions). There are two classic examples about why we need to use science in medicine: one ancient - the common use of bleeding for all kinds of ills from the 2nd century AD until the last century; one recent - the routine use of estrogen hormone replacement therapy from the 1970s until a few years ago, when benefits were disproven and harms were shown with randomized clinical trials (RCTs). A psychiatrist blogger with an anti-pharmaceutical industry philosophy critiqued my article on the grounds that he thought I was saying that the RCTs failed to show benefit with estrogens only in some conditions, but not others. His/her (anonymity reigns here too) critique was that RCTs cannot feasibly show benefit in many conditions where clinical experience seems to suggest such benefit. He/she quotes me as follows:

"Hormone replacement therapy was the cure for many female illnesses. Decades of experience with millions of patients, huge observational studies with thousands of subjects, and the almost unanimous consensus of experts all came to naught when randomized studies proved the futility of the belief in that treatment (not to mention its carcinogenic harm)."

The blogger responds:

"A moment's reflection shows this argument to be illogical. Hormone replacement therapy did work. It had great risks, but to say that it was a failure is wrong. ‘It was the cure for many female illnesses, but...' So it was adequately tested in all of them, indicating its futility? Ghaemi would respond that we would need more studies to determine the efficacy and risks in each indication, in each population. That would be right, but that's not what happened: doctors generalized the failure of a medication based on the outcomes in a restricted symptom set."

That's not how Ghaemi would respond.

One wishes that the commentator had spent more than a moment to reflect on my article. If he/she had looked at the actual RCT, he/she would have seen that indeed this study was huge enough and looked at enough multiple outcomes such that it adequately tested and disproved the benefits of hormone replacement therapy for those outcomes, indicating the overall futility of that treatment.

One has to keep in mind that the claim was that estrogen hormones were beneficial for everything and anything under the sun - especially osteoporosis, prevention of heart disease, prevention of dementia, and psychological symptoms of menopause. I did not claim that they had no utility for anything,  but they that did not work for most of the benefits claimed, and that this inefficacy was now proven with this definitive RCT. We did not need to wait for more research. A recent reanalysis shows that the major RCT found increased risk of breast and endometrial cancer, stroke and heart disease. Effects on cognition remained uncertain, and benefit for osteoporosis were seen. Estrogen treatment was futile for many female illnesses, which is what I said. That it might help osteoporosis, or even psychological symptoms of menopause, is meaningless unless we are aware of the many areas of proven inefficacy, as well as the newly proven harms. Not surprisingly the blog author does not say anything about the proven increase in cancer rates shown by the RCT.

What follows in that blog is a long list of me-too comments by the true believers in the notion that doctors are horrible, medicine is all biased, there is no such thing as scientific truth, and that money buys everything. This is where we get to my moment of internet infamy. Someone followed up such fulgent commentary with four letters prior to my name. (The blog author appears to think such polished prose is not worthy of deletion).

And so here is my response. The original blog posting is mistaken, for the reasons given above; the commentary jejune, for reasons my mother taught me in preschool.

Which brings us back to the topic: Why all the passion about evidence-based medicine? Why all the anger at science?

A legitimate source may be where pseudoscience masquerades as science, either because of capitalist intrigue, or simple credo. (One finds this pseudoscience, by the way, both among the opponents and proponents of the pharmaceutical industry). An illegitimate, and far deeper source, I think, is cultural; here again nasty postmodernist rejection of science rears its head. Such persons take their vaccines as children, and their antibiotics as adults, and live, where a century ago they would have died, and then they have the nerve to spout off against science.  Politely, of course.

I have a suggestion: Let those opponents of science refuse to ever take any medication for any reason ever again, and return to the days of non-evidence based-medicine, with bleeding as the only medical treatment acceptable to them.  Then at least they could be honestly impolite. 

About the Author

Nassir Ghaemi

Nassir Ghaemi, M.D., M.P.H.,

is Professor of Psychiatry at Tufts University School of Medicine, and Director of the Mood Disorders Program at Tufts Medical Center in Boston.

You are reading

Mood Swings

He's Abnormal, She's Normal: That's (A Reason) Why Trump Won

How the temperament criticism of Trump backfired

Not "Depression": Manic-Depression and Robin Williams

A deadly disease, whether we accept it or not