If there’s one thing everyone agrees on, it’s that preventive care is always a good thing. Well, I’m a doctor and I’m afraid of preventive medicine.

The theory behind preventive medicine is sound. It is better to treat prevent disease than to treat it. It is better to refrain from smoking and never get lung cancer than it is to treat lung cancer. It is better to refrain from alcohol abuse than to treat alcoholic cirrhosis of the liver. In each of those cases, avoiding a behavior known to cause the disease is highly effective in reducing the incidence of the disease.

But not all preventive medicine is about avoiding behaviors known to cause diseases. Preventive medicine has held out the possibility of avoiding naturally occurring diseases by correcting hormone, mineral or other imbalances through eating specific foods, taking supplements or using medication. Many of these preventive efforts have not only been unsuccessful, they have created problems of their own, sometimes the very problems they were meant to prevent.

The paradigmatic example is estrogen replacement therapy. Menopause, characterized by a lack of estrogen, is associated with increased risk of a variety of health problems including heart disease and osteoporosis. The reasoning behind estrogen replacement therapy was that if heart disease or osteoporosis are associated with decreased estrogen, replacing that estrogen will reduce heart disease and osteoporosis. There was some experimental evidence supporting that theory, but not a lot. Nonetheless, estrogen replacement therapy became the standard of care well before large scale, long term studies could be completed. It was preventive therapy; how could it cause any harm?

Merely replacing a missing hormone is not as simple as it sounds. Hormones, like many other substances in the body, are involved in more than one system. Indeed, lots of substances play multiple roles in multiple systems. Adding back the missing hormone can have an impact far beyond the system it was designed to protect and that impact can be harmful. The data is not final, but it appears that adding back estrogen increases the risk of breast cancer. And while estrogen replacement did have a beneficial effect on bone health, large scale, long term studies have not delivered the promised benefit of reducing the risk of heart disease. Routine postmenopausal estrogen replacement is no longer the standard of care; it is reserved only for specific situations in which the benefit is judged to be worth the risk.

With routine estrogen therapy contraindicated, the search continued for non-hormonal methods of preventing osteoporosis. Bisphosphonates appeared to promote bone health without the side effects of estrogen. Again, large scale, long term studies were lacking, but it was preventive therapy; how could it cause any harm? Unfortunately, it has turned out that biphosphonates may not promote bone health, but may weaken bones. The bisphosphonate Fosamax has already been linked to osteonecrosis (bone destruction) of the jaw, and now it appears that long term use of Fosamax may result in severe weakening of the femur bone (the thigh bone) leading to fractures that during activities as simple as walking.

Reversal of deficiencies associated with aging is not the only place where preventive medicine has gone wrong. Preventive medicine also rests on the premise that early diagnosis is better than late diagnosis, and that anything that increases the likelihood of early diagnosis must be beneficial. The most spectacular example of that faulty reasoning is the PSA (prostate specific antigen) test. Since increased PSA is associated with prostate cancer, doctors began recommending routine PSA screening, despite the fact that there were no large scale, long term studies demonstrating benefit. It was preventive medicine; how could it cause any harm?

Listen to what the test’s inventor, Dr. Richard Ablin, has to say about its use: “I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster.”

According to Dr. Ablin:

… [T]he test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t.

Instead, the test simply reveals how much of the prostate antigen a man has in his blood. Infections, over-the-counter drugs like ibuprofen, and benign swelling of the prostate can all elevate a man’s P.S.A. levels, but none of these factors signals cancer. Men with low readings might still harbor dangerous cancers, while those with high readings might be completely healthy.

Millions of men have been subjected to unnecessary biopsies, and harmful treatments, and billions of dollars have been wasted on this failed exercise in preventive care.

What can we learn from these and other similar debacles? We need to reexamine the basic premises of preventive medicine. Sure it is better to prevent disease than to treat it, but that does not mean that reversing the metabolic changes that accompany a disease will prevent it or will prevent it without causing serious unforeseen complications. Sure it is better to treat early stage cancer than late stage cancer, but a screening test that makes lots of mistakes can be worse than no screening test at all.

Most importantly, we must never forget that preventive medicine is a branch of medicine, in the exact same way that cardiology and neurology are branches of medicine. As such preventive medicine must be held to the same standards; any treatment, even a preventive treatment, must be tested in large scale, long term studies before being put into routine clinical use. Preventive medicine, like other branches of medicine, has the power to harm as well as to help. We ignore that fact at our own peril.

As predicted, VBAC activists are clinging to their resentment and aggressively ignoring reality.

Amy Romano on the Lamaze blog asks the bizarre question: Do women need to know the uterine rupture rate to make informed choices about VBAC? It’s bizarre because she implies that this is a medical question and that the answer is unknown. However, this is a legal question and the answer has been clearly established by the courts. Not only is knowing the rupture rate required, it isn’t even enough. Women must “understand” the rupture rate and many women have successfully argued that they are incapable of understanding.

Don’t believe me? Consider what the “Syracuse NY Birth Injury Lawyers” have to say on the subject:

For an expectant mother to give meaningful and informed consent she must be specifically told and understand that “IF HER UTERUS RUPTURES DURING HER VBAC, THERE MAY NOT BE SUFFICIENT TIME TO OPERATE AND TO PREVENT THE DEATH OF, OR PERMANENT BRAIN INJURY TO, HER BABY.” (emphasis in the original)

Courtmoom Mama, writing on the Unnecesarean, helpfully illustrates how VBAC activists desperately cling to their resentment. In her post NIH VBAC Consensus Development Conference: Gift Horse or Trojan Horse? she is most excited about the fact that an activist aggressively challenged a panel member, presumably “speaking truth to power.” Courtroom Mama (a self described “law geek”) utterly ignores the medico-legal issues that restrict availability of VBAC.

Most egregious, though, is the penchant of VBAC activists to invent rights that don’t exist. Henci Goer’s bemoans the “[f]ailure to recognize that VBAC is a right.” Yet there is no legal right to VBAC. Indeed, there is no legal right to healthcare of any kind, let alone a right to a specific procedure. A “right” to VBAC implies an obligation on the part of doctors and hospitals to preside over VBACs, justifying resentment of obstetricians for depriving women of their “rights.” However, since there is no “right” to VBAC, doctors and hospitals cannot be accused of violating anyone’s rights.

Asserting a non-existent right is worse than pointless. It demonstrates an inability to understand and frame the real situation in favor of a make-believe world where evil obstetricians control everything. In the real world, women have only the right to refuse medical treatment, not a right to demand a specific treatment. Moreover, doctors and hospitals have no legal obligation to comply with patients who refuse medical advice or demand procedures that the doctors or hospitals do not provide.

And speaking of “procedures,” activists who attended the conference impressed themselves with their clever observations on semantics. According to Goer:

VBAC … is not a procedure. Labor is what inevitably happens at the end of pregnancy.

That point, currently bouncing its way around the Twitter universe, is simultaneously inane and irrelevant. Are doctors supposed to bang themselves upside the head and suddenly realize that VBACs don’t pose additional risks because they aren’t “procedures”? Are lawyers supposed to have a sudden epiphany that detailed consents aren’t required for VBACs because they aren’t “procedures”? Why don’t VBAC activists notice that no one beside themselves is impressed with their “cleverness”?

VBACs have been dramatically restricted because of legal and insurance concerns. There’s no one to “blame” because everyone involved is doing their job within medical and legal constraints that we all must acknowledge. Unfortunately, being deprived of the opportunity to blame obstetricians appears to be insupportable to VBAC activists. They demonstrate a greater commitment to made up reasons for resentment than to practical solutions for making VBAC more widely available. Indeed, they are so committed to resentment that they appear incapable of addressing reality.

The NIH Consensus Conference on Vaginal Birth After Cesarean has just released its findings. Despite the fact that the conference statement offers strong support for a far more liberal VBAC policy, VBAC activists are currently parading before the panel during the public comment portion and attempting to outdo each other in their vilification of doctors. It’s almost as if the panel findings are irrelevant. Their anger, self pity, and conspiracy theories are so important to activists, that they cannot let them go. In fact, they appear to be far more important to activists than the actual issue under discussion.

The NIH conference on VBAC was convened because doctors and policy makers (as well as patients) believe that the current VBAC policy is misguided and potentially harmful. As the statement explains:

Vaginal birth after cesarean (VBAC) describes vaginal delivery by a woman who has had a previous cesarean delivery… In 1980, a National Institutes of Health (NIH) Consensus Development Conference Panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered. The option for a woman with a previous cesarean delivery to attempt a trial of labor (TOL) was offered and exercised more often in the 1980s through 1996. Beginning in 1996, however, the number of VBACs has declined, contributing to the overall increase in cesarean delivery …

Although the number of women … faced with the question of whether to attempt TOL has markedly increased, there has been a concurrent, dramatic drop in VBAC. Yet cesarean and VBAC rates are identified as quality indicators for maternal health by policymakers, insurance providers, and health care quality monitoring groups. Success of TOL is consistently high (60 to 80 percent), whereas the risk of uterine rupture is low (less than 1 percent)…

In other words, in 1980, after reviewing the scientific literature, an NIH panel recommended offering a trial of labor to women who had had a previous C-section. As a result, VBAC became popular. Many women had successful vaginal deliveries. Only a very small proportion of women had serious complications, almost exactly what was predicted. Yet the VBAC rate peaked in 1997 and has declined precipitously since the, as the following graph shows.

Why did VBACs decline despite the fact that the benefits and risks were exactly as predicted? The answer can be summed up in one word: lawsuits. Although women offered VBAC were counseled about the small risk of uterine rupture (opening of the uterine scar during labor) and the attendant risk that the baby might die in the event of a rupture. Nonetheless, when a baby died after a uterine rupture, many mothers sued, and claimed that they had not “understood” the risks even though those risks were clearly explained. Juries were moved by these emotional appeals, and large judgments were paid out.

What did everyone learn from these lawsuits? Doctors learned that patients maintained that they could not “understand” risks no matter how carefully explained, patients learned that they did not have to take responsibility for their decisions, and lawyers learned that VBAC complications represented a bonanza.

The American College of Obstetricians (ACOG) stepped into the breach and, attempting to make things better, made them far worse. ACOG likes to remind its members that doctors have never lost a lawsuit in which they followed ACOG guidelines. Therefore, ACOG decided to promulgate guidelines that doctors could use in their legal defense. Unfortunately, the ACOG guidelines were so strict (unreasonably strict in the eyes of most obstetricians) that most obstetricians could not meet them. ACOG mandated that VBAC should only be attempted when both an anesthesiologist and obstetrician were present so that anyone who experienced a uterine rupture could be treated immediately. Most medium sized and small hospitals cannot afford to have an anesthesiologist in the hospital around the clock. Most obstetricians cannot afford to sit for hours while a patient labors. Therefore, many hospitals and anesthesiologists stopped offering VBAC.

The problem was compounded when malpractice insurers recognized that VBAC complications, though uncommon, represented an indefensible claim. If patients could claim that any consent for VBAC was essentially invalid, large payouts were inevitable. Many malpractice insurers told obstetricians that they should not preside over VBACs and, if they did, their entire malpractice policy would be voided. Obstetricians cannot practice without insurance; defying the insurer meant that an obstetrician would have to quit obstetrics altogether.

Simply put, liability concerns have sharply restricted the availability of VBAC. But that’s not how VBAC activists tell the story. Like many advocates of alternative health, childbirth activists thrive on resentment. Any situation that they don’t like is automatically ascribed to a conspiracy of evil doctors. VBAC activists insist, despite the copious evidence to the contrary, that doctors deliberately and maliciously chose to restrict VBAC. They have all sorts of purported “reasons” for this conspiracy. They claim that obstetricians make more for C-sections (for most doctors, and all doctors on salary, that is not the case), that doctors want to ruin women’s birth “experiences,” and that doctors are more concerned about protecting themselves (avoiding the loss of insurance) than about offering good medical care. They refuse to see that on the issue of VBAC, obstetricians are their allies.

The latest NIH panel reviewed the scientific literature and confirmed their earlier stance. VBAC should be offered to eligible women because the chance of success is high and the risk of complications is low. Furthermore, the conference report urged ACOG to re-evaluate their VBAC guidelines, presumably to eliminate the need for continuous presence of both anesthesiologist and obstetricians. In addition, the panel recommended that policy makers review the medico-legal strictures on VBAC, since liability concerns are driving the restriction of VBACs.

Despite all this, VBAC activists are still complaining about evil obstetricians. The public comment session immediately following presentation of the report was dominated by VBAC activists with inane demands for revision of the report. Chief among those demands was the insistence that doctors be blamed for the current situation. It makes me wonder whether these women even bothered to read the report. Or perhaps they read it but didn’t care that it represents the most promising avenue for increasing access to VBAC. Resentment is such an integral part of VBAC activism that it appears to be more important than VBAC itself.

I watched the web cast of the NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights, which is occurring this week. Dr. Michael Socol, chief of OB-GYN at Northwestern, distilled the problem down to its essence. He said (I am paraphrasing) that if it were possible for women to sign a binding consent giving up their right to sue in the event of uterine rupture, there would be no need for the conference. Every doctor would be offering a VBAC to every eligible patient.It is liability that is driving the restriction of VBAC. Successful lawsuits have led malpractice insurers to void a doctors’ malpractice policies for presiding over VBACs.

Unfortunately, the law does not allow patients to sign away their right to file malpractice suits. Since that is the case, doctors have stopped doing VBACs.

During the question and answer session, a woman (it looked like Henci Goer, but the lighting was too poor to be sure) made the typically sanctimonious comment that patients should be “informed” that doctors would putting their liability concerns ahead of the patients’ well being. The comment accomplished nothing beyond demonstrating that the woman had no understanding of the issues involved.

Let me make it easier for VBAC activists to understand:

What would you do if your health insurance company made a rule that anyone who attempts a VBAC would automatically void their health insurance policy and lose all coverage forever. In other words, you’d be on the hook for your $15,000 hospital stay and your baby’s hospital stay. Not only that, your well baby visits to the pediatrician would no longer be covered. Your older child’s epilepsy medications would no longer be covered, nor would his occupational therapy. Your husband would have to pay for the medication used to control his blood pressure. You’d be out at least an additional $10,000 each and every year forever.

On the other hand, if you consented to an elective repeat C-section, everything would be covered and you would not lose any insurance benefits.

What would you do then? Would you be willing to void your health insurance policy and threaten the financial security of your family in order to have a vaginal delivery? Is a vaginal delivery worth paying $15,000 out of pocket AND all your health expenses for the rest of your life, totaling hundreds of thousands of dollars?

And if it’s not worth voiding your health insurance policy and being personally responsible for tens or even hundreds of thousands of dollars, why is it worth voiding a doctors’ malpractice policy?

Homebirths advocates are touting a reported increase in homebirths from 2004-2006. They ought to look at the actual numbers a bit more closely before they get excited. They don’t seem to realize that the homebirth rate in 2006 is exactly the same as it was in 2000. Homebirths still represent only a minuscule proportion of births in the US.

According to Trends and Characteristics of Home and Other Out-of-Hospital Births in the United States, 1990–2006:

In 2006, there were 38,568 out-of-hospital births in the United States, including 24,970 home births and 10,781 births occurring in a freestanding birthing center. After a gradual decline from 1990 to 2004, the percentage of out-of-hospital births increased by 3% from 0.87% in 2004 to 0.90% in 2005 and 2006. A similar pattern was found for home births. After a gradual decline from 1990 to 2004, the percentage of home births increased by 5% to 0.59% in 2005 and remained steady in 2006… About 61% of home births were delivered by midwives. Among midwife-delivered home births, one-fourth (27%) were delivered by certified nurse midwives, and nearly three-fourths (73%) were delivered by other midwives.

In other words:

From 2004 to 2005 out of hospital births (planned plus unplanned) increased from 0.87% of births to 0.90% of births; there was no increase from 2005-2006. Among births at home from 2004-2005 (planned plus unplanned) there was an increase from 0.56% to 0.59%; there was no increase from 2005-2006. But the homebirth rate dropped from 2000-2004, so the purported “increased” homebirth rate in 2006 is actually unchanged from the homebirth rate in 2000.

addendum: This graph makes it easier to see what happened.

The helicopter parent is dead. Long live the snowplow parent!

We’ve all heard of helicopter parents, mothers and fathers who hovers over a child’s every decision and action. Evidently helicopter parents have evolved into the snowplow parent s “who determinedly clears a path for their child and shove aside any obstacle they perceive in the way.”

So says Craig Lambert in an article in this month’s issue of Harvard Magazine. The article, Nonstop: Today’s superhero undergraduates do 3,000 things at 150%, detailing the frenetic pace and relentless ambition of today’s undergraduates is by turns horrifying and depressing.

Students today routinely sprint through jam-packed daily schedules, tackling big servings of academic work plus giant helpings of extracurricular activity in a frenetic tizzy of commitments. They gaze at their Blackberries … to field the digital traffic: e-mail and text messages, phone calls, Web access, and their calendars. Going or gone are late-night bull sessions with roommates and leisurely two-hour lunches …

There’s a wide consensus that today’s undergraduates make up the most talented, accomplished group of polymaths ever assembled in Harvard Yard: there’s nothing surprising about meeting a first-chair cellist in the Harvard-Radcliffe Orchestra who is also a formidable racer for the cycling club, or a student doing original research on interstellar dark matter who organized a relief effort in sub-Saharan Africa…

The paradox is that students now live in such a blur of activity that idle moments for such introspection are vanishing. The French film director Jean Renoir once declared, “The foundation of all civilization is loitering,” saluting those unstructured chunks of time that give rise to creative ideas. If Renoir is right, and if Harvard students are among the leaders of the future, then civilization is on the precipice …

What’s driving this frenetic activity? Relentless ambition that starts surprisingly early:

Busy parents book them into things constantly—violin lessons, ballet lessons, swimming teams. … Dingman [dean of freshmen] notes that, “Starting at an earlier age, students feel that their free time should be taken up with purposeful activities…

Home life has changed in ways that would seem to undercut children’s development of autonomy. There was a time when children did their own homework. Now parents routinely “help” them with assignments … Youngsters formerly played sports and games with other children on a sandlot or pickup basis, not in leagues organized, coached, and officiated by adults … Once, college applicants typically wrote their own applications, including the essays; today, an army of high-paid consultants, coaches, and editors is available to orchestrate and massage the admissions effort.

Parents have created this culture. As Lambert explains, ” The strategizing starts early; today’s parents groom their children for high achievement in ways that set in motion the culture of scheduled lives and nonstop activity… “

While “snowplow parents” seem to be a new phenomenon, I suspect that are just a variation on a phenomenon as old as recorded history: wealthy parents ensuring children’s success by paving the way with money and social connections. The prep school has been replaced by the public high school with multiple AP courses, the European grand tour has been replaced by the summer trips to far off lands, the social clubs replaced with the National Honor Society as the reward for extensive tutoring, special courses and advanced summer programs. Money, copious amounts of it, is usually required.

Sure anyone can go to public school, but very few can afford to live in the communities with the best schools; schools are usually funded by property taxes and estate sized homes for wealthy families provide an excellent tax base. Those fabulous summer trips to work on a dig in Egypt or study intensive Italian in Florence cost a fortune. And tutors, special courses and advanced study at college programs designed for high school students don’t come cheap.

It used to be that money and social connections assured a child’s success. Now actual merit is required, but money and social connections pave the way just as they always did. An outstanding athlete requires talent, but talent can honed with private coaches and exclusive leagues. To become a brilliant scientist requires brilliance, but a summer working in the award winning lab of Dad’s medical colleague gives a teen an undeniable advantage. And woe to the child who has not devoted serious time to “social action,” time that children of modest means must spend at work in order to help their families make ends meet.

Not only do parents script their children’s lives and pay for every possible advantage, they run roughshod over anyone and anything that dares to stand in the way. It’s bad enough that they will not back teachers in ensuring good behavior in schools, but it is ridiculous that they expect to be able to call a college to “check up” on their sophomore, and it is downright harmful that some come along to job negotiations or try to amend grades in law school.

Snowplow parents forget that their principle job is not to make sure that a child is successful, but to make sure that a child becomes a competent adult; the success will follow if it is merited. Any parent who is calling their child’s law school professor has no faith that the child can perform even the most basic tasks of adulthood, hardly surprising since the parents never taught them how.

Snowplow parents believe they are helping their children, but in many cases they are hurting them. They are depriving them of the opportunity of gaining competence by overcoming disappointment or by striving to reach goals instead of having the goals slid to within easy reach. How will these children make their way in the world when their parents are gone? How will these children learn to value themselves for who they are instead of what they achieve? And how will these children handle the disappointment of realizing that it may not always be possible to achieve what they desire?

Parents should be active and involved in their children’s lives. And parents sometimes have to run interference for children, particularly when children are young and vulnerable to the whims of teachers and coaches who may be cruel or unfair. But that does not require a snowplow, it doesn’t even require a shovel. It requires a more subtle tool such as a broom, one that gets smaller and smaller as the years pass until it finally fades away altogether.

A child in college should be competent enough to manage anything that comes along outside the realm of a true disaster like sexual harassment on the part of a professor, or a roommate who is mentally ill, in other words, very rare occurrences. If a parent cannot trust a child to manage on his own at college or beyond, then something is wrong, not with the child, but with the parent, who failed to ensure that the child gradually learned to handle the basic tasks of adulthood.

Homebirth advocates like to tout the many “advantages” of giving birth at home. High on the list is limiting exposure to hospital acquired infections, and since only your “own germs” are in your home, you are protected. Yes, you are protected from hospital acquired infections, but the most dangerous infectious agents are actually those that live inside the mother, not the ones in the hospital. Consider that for newborns both Group B strep and herpes virus represents potentially deadly threats. And both Group B strep and herpes virus are infectious agents carried by the mother. In other words, the most deadly infectious threat to the baby is the mother herself.

For mothers, the most common infectious risk is a uterine infection. Once again the infectious agent is usually a bacteria living in the vagina. Homebirth advocates like to fling accusations about women who contract life threatening sepsis at home and are fond of pointing out horror stories like the unfortunate woman in Florida who ended up losing parts of multiple limbs due to Group A strep (“flesh eating” bacteria) sepsis. But what they don’t realize is that approximately 90% of cases of Group A strep sepsis are acquired outside the hospital because the bacteria lives in the community. Usually it is harmless, but when it invades a wound (like the raw surface of the inside of the uterus after birth), the results can be disastrous.

It appears that this has happened in a small Texas town. According to the local paper:

A few weeks ago, a perfectly healthy Katy gave birth to daughter Arielle, only to experience an intense and prolonged pain after the birth.

… Doctors at Kingwood Medical Center eventually discovered the new mom had a Streptococcal A infection that had aggressively invaded her body.

As a result, Katy has experienced multiple organ failure and is unconscious. Surgery last week involved the removal of several sepsis organs. She is currently on a ventilator and is receiving dialysis.

Katy had had an eight hour, drug-free, intervention free labor and delivered a 10 pound baby girl … in a planned homebirth.

Of course, the result may not have been any different had Katy given birth in the hospital, since she would have brought the bacteria in with her. And that is the important point to keep in mind. While hospital acquired infections are a serious problem for the elderly and the immuno-compromised, they are far less common in obstetric care. During childbirth, the bacteria and viruses that pose the greatest threat to babies and mothers are those carried by the mother herself. Homebirth does not offer protection against serious neonatal and maternal infections, because the most dangerous “germs” are “your own germs at home.”

Katy has no health insurance. A variety of events are being held to raise money for her and her family. Find out more here.

What do episiotomy and Cesarean section have to do with Hitler? Nothing, actually, but it did catch your attention. Perhaps it was simply to catch your attention that Dr. Michael Klein entitled his editorial in this month’s edition of the journal Birth What Do Episiotomy and Cesarean Have to Do with Copernicus, Galileo, and Newton? Episiotomy and Cesarean section have nothing to do with Copernicus, Galileo and Newton, either.

Yet I suspect that the title was more than a cheap bid for attention. Rather, it was an example of the ludicrous grandiosity of Dr. Klein and certain other critics of modern obstetrics: he actually believes that he should be included in the pantheon of scientific immortals, among Copernicus, Galileo and Newton. In other words, Dr. Klein suffers from the “conceit of the brilliant heretic.”

Consider the way he begins his essay:

Like those who thought the world was flat and the sun revolved around the earth, believers in routine episiotomy considered its use as based on “normal science,” as defined by Thomas Kuhn, and fully accepted within the obstetrical/gynecological community — a discipline that saw birth as inherently abnormal, and whose scientific questions were based on this conception of reality as the only framework for legitimate inquiry…

In the early 1980s, I pondered how to get funded for a randomized controlled trial of an accepted procedure that I thought was inappropriate when applied routinely. Later I struggled to get the episiotomy trial published when the dominant culture
wanted the results buried. In this context, I thought about how strongly held beliefs came about and the critical importance of timing. And then I discovered
“paradigm shift,” as coined by Kuhn.

So obstetricians who used episiotomies were flat-earthers, awaiting the arrival of a man of extraordinary brilliance like Michael C. Klein, MD, CCFP. But when the great man appeared in their midst, those ignorant obstetricians did not recognize his brilliance (possibly because it was blocked by the size of his enormous ego). Fortunately, he can soothe himself by comparing their response to those who refused to recognize the seminal insights of Copernicus, Galileo and Newton. He, too, was persecuted for his earth shattering insights.

Sound familiar? It’s the “conceit of the brilliant heretic” that refuge of crackpots everywhere. I have written about it before. As explained in The Holistic Heresy: Strategies of Ideological Challenge in the Medical Profession by Paul Wolpe, Klein believes:

[His view] is the inevitable (or desirable) next step in the history of medicine, and like other heroes of medical history who were initially rejected by the orthodoxy of the day … [he] is simply ahead of his time. Innovation is always initially resisted … [People like Klein] portray themselves as mavericks, leaders, with every expectation that soon all of medicine will, by necessity, follow in their footsteps.

It is a conceit of monumentally embarrassing proportions. Klein imagines that his work on episiotomy is of equal importance to the theory of the Earth revolves around the sun. Klein dares to equate the way obstetricians treated his hypothesis with the persecution of Copernicus and Galileo. Really, Dr. Klein? Did anyone threaten to kill you for your beliefs? Did they threaten to excommunicate you from your religion? What, after all, did they do to you? Evidently they failed to recognize your genius, in your mind a sin every bit as monstrous as the threats to Galileo’s life.

By the way, Dr. Klein, including Newton betrays a deficit in your knowledge of history. Newton was not persecuted. He was a founding Fellow of the British Royal Society, which as the name implies, was blessed with a royal patron, no less than the king himself. You can’t get recognition more official than that. But I guess the temptation to compare himself to Newton was too great for Dr. Klein to resist, regardless of historical inaccuracy.

I’m going to go out on a limb here and assert that Dr. Klein’s finding that routine episiotomy might increase the risk of severe perineal tears is NOT equivalent to the insight that the sun is at the center of the galaxy, even if it were true; and his findings have not been reproduced often enough to be sure that he is correct. Indeed, recent scientific evidence suggests that the decline in episiotomies has not been followed by the decline in perineal tears in the magnitude that his finding predicts.

I’m also going to give Dr. Klein a bit of friendly advice. If he intends to be taken seriously, and not laughed off the stage at future professional meetings, he ought to stop comparing himself to the immortals of science. He is not one of them. He should be profoundly embarrassed that he dared to mention his own name in association with theirs.

I’ve got news for Dr. Klein. His findings are not earth shattering. They have not changed much of anything in modern obstetrics, let alone ushered in a new paradigm. They are a few paltry observations on the possible consequences of a minor surgical procedure, nothing more and possibly a lot less.

One of the big problems with science is that you do the experiment and it doesn’t support your thesis. What to do? Slice and dice the data to make it look better, of course.

That’s just what happened in a study that purports to show that acupuncture alleviates depression in pregnancy. This would be an important finding if it were true, since some pregnant women suffer from depression and are wary of the risks of taking antidepressants in pregnancy.

In Acupuncture for Depression During Pregnancy, the authors set out to investigate whether acupuncture could alleviate symptoms of depression:

Qualified participants were randomized to acupuncture specific for depression, acupuncture not specific for depression, or prenatal massage…

Acupuncture specific for depression was tailored individually to address each participant’s depression-related patterns of disharmony according to the principles of traditional Chinese medicine and following a published standardized treatment manual.26 Acupuncture not specific for depression was also standardized and needles were inserted in real acupuncture points that did not address depression-relevant patterns of disharmony according to traditional Chinese medicine…

Swedish massage was provided in a standardized fashion and included effleurage and pétrissage strokes…

There were 141 participants in the study, randomized as follows: 46 received acupuncture specific for depression, 48 received acupuncture not specific for depression and 40 received massage. Response to treatment was defined as a more than 50% reduction on the Hamilton Rating Scale for Depression, as well as a HRDS score between 7-14. In other words, the patients were still depressed, but their symptoms had decreased markedly. Remission was defined as achieving an HRDS score of less than 7.

Did acupuncture specific for depression result in remission of depression. The authors acknowledge that it did not.

Remission rates were not significantly different between the group receiving acupuncture specific for depression (16 of 46, 34.8%) and the combined control groups (26 of 88, 29.5%; number needed to treat 19.1); the remission rates for the groups receiving acupuncture not specific for depression and prenatal massage did not differ (11 of 40, 27.5%; and 15 of 48, 31.2%, respectively; number needed to treat 26.7). Acupuncture specific for depression remission rates did not differ from either the group receiving acupuncture not specific for depression (P=.47; number needed to treat 13.7) or prenatal massage (P=.72; number needed to treat 28.3).

But did acupuncture for depression produce an improvement in symptoms (a response)? The authors claim that it did, stating:

Response rates were significantly higher for the group receiving acupuncture specific for depression (29 of 46, 63.0%) than for the combined control groups (39 of 88, 44.3%; P<.04)... The control interventions did not differ from each other, 15 of 40 (37.5%) for the group receiving acupuncture not specific for depression and 24 of 48 (50%) for the group receiving prenatal massage; P=.24)...

But on closer inspection, the data does not support the authors’ claims. Yes, the data show that acupuncture specific for depression produced a statistically significant higher rate of response than non-specific acupuncture (63% vs. 37%). And the data also show that acupuncture for depression produced a statistically significant higher rate of response than found in a group created by combining non-specific acupuncture + massage (63% vs, 44%). But, the difference between the response rate for acupuncture specific for depression and massage was not statistically significant (63% vs. 50%; P=0.20).

In other words, acupuncture specific for depression produced an effect that was not different from that of one of the controls. But by creating a group that combined non-specific acupuncture (ineffective) with massage (effective), they were able to create a composite that was ineffective, and then they compared the experimental group with the composite. But that doesn’t change the fact that acupuncture for depression was no better than massage.

Have the authors shown that acupuncture specific for depression is effective for treating depression in pregnant women? I don’t think so. If it offers no advantage over massage, we can forget about acupuncture and simply offer depressed pregnant women a day at the spa. It is no less effective and probably far more enjoyable.

Folks, you are the first to know: I quit Science Based Medicine. What a relief!