August 04, 2016
I have decided not to be a Snake Oil salesman!
I have decided not to be a Snake oil salesman!
My recent post on taking up a career as a Snake oil salesman attracted a lot of attention. I received a mixture of comments. Some were good and some pretty bad! But this is the world of social media. I have thought again and I really believe in my new treatment. This is a short post on what I am going to do….
- I will not promote my treatment unless I have evidence to support its effectiveness
- It will be my role to discover this evidence, but I will need some help.
- I will critically look at the results of my treatment for all the patients that I have treated with the new technique. I will do this by taking and analysing good clinical records.
- I will present the data as a case report or case series. I will even try and get it published. But if this is not successful I will take note of the comments that the reviewers have made.
- I will seek the advice and help of an experienced research leader in my field. I will listen to their advice and take it on board. If they do not think that my new treatment is unlikely to be effective, I will seek out other researchers, but still listen to what they say.
- Hopefully, I will gain support to start some clinical research into my treatment. This will need ethical committee approval. But this is the correct way to move my treatment forwards.
- This will be difficult, but I realise that research is difficult and time consuming. I will still not be able to sleep at night because research is exciting!
Emeritus Professor of Orthodontics, University of Manchester, UK.
Hi Kevin
Now you will be in peace and sleep better (loosing just some nights)…After reading your two posts, I think it is possible to be successful in business respecting the evidence based science premisses. Sometimes it is a long long way, as you said, but it is trustful. It is interesting to see that all this important discussion is surrounded by ethics principles. This is a good topic for the future!
Dear Kevin ,
Both you and your scheme have lost my confidence.
I refuse to be an acolyte of someone who does not wish to be a demigod…… at least not quickly and without rigor.
Love your work,
I like your creativity, but this is reaching a sad level. Do you still claim that this is not slander? Give me a break
Yes, this is not targetted at anyone in particular, there is a lot of misinformation in dentistry and this post was based on combination of the things that I had observed. This current post was to provide information on what should be done if someone has a good idea. Again, it is not directed at anyone, apart from someone who wants to carry out some research to develop a treatment that they have discovered
The problem that I find in these types of discussions is that the status quo is viewed as the “Gold Standard” to which all other therapies must be compared. If the new idea doesn’t meet critical standards of examination then it is “Snake Oil”. I am a Prosthodontist and know that literature far better than the orthodontic material so I will use it as my example. The “Gold Standard” in occlusion is centric relation, bilateral simultaneous contact, and canine disocclusion. Any concept that falls outside of that standard is seen as heretical and its’ practitioners’ as Snake Oils Salesmen. Two interesting points: First, most of the research on occlusal concepts came years after the foundation was established. Develop a concept and then find data to support it! Second, the research, for the most part, is horrible. It cannot meet the rigor of today’s evidence-based pandemic. If, for example, neuromuscular occlusal concepts had come along first and became our status quo, the evidence for centric relation dentistry probably would not be strong enough to dissuade you from NM. My point to this is rant is that in a discussion of new concepts do not place so much weight on the status quo as to not see that its’ strength simply comes from acceptance and time not necessarily from scientific support.
I very much appreciate you efforts and insights and rely on them. I have found the information to be cery helpful clinically and am personally grateful to you and on behalf of my patients.
As a grand master of the AAAFEO (American Association of Airway Friendly Epigenetic Orthotropists) I must vociferously register a protest against this so-called evidence-based treatment. This push for evidence does not allow alternative, unproven and non-scientific therapies to be propagated with the same ease as scientific research. Does expert opinion not count for anything anymore? Research may be exciting, but fabricating biologically implausible theories is exhilarating!
Kevin,
I think this pivot is a good one. Satire seemed to have gone over the heads of many of the people who really need to hear your insights.
On a different but related note; have you read the book “Thinking Fast and Slow” by Danial Kahneman? It has given me great insight into why some orthodontists hold so tightly to ideas that have no or very little evidence to support them. I would recommend this book to any orthodontist who shares Kevin’s point of view and have trouble understanding how other orthodontists can be so ………misguided…. while truly believing they are working in the best interests of their patients.
The bottom line is that our brains are wired to jump to conclusions and believe a good story and this brain tendency is much more powerful than the part of the brain that understands statistics. There is actually a chapter on why a good story always trumps good statistics.
I have found this book extremely helpful when discussing orthodontic concepts and controversies with referring dentists. It has also helped me change my message to patients when they appear in my office for a 3rd opinion and are complexly confused by the differences in possible treatment plans.
I suspect you have read it but I also wanted to get the title out to your like minded readers as I think they will find it interesting and very relevant to understanding what is happening in orthodontics today.
John McDonald
Salem, Oregon
Hi John, thanks for the sensible comments and while I had read Kahneman’s book, I had missed the points that you made. I will read it again!
I very much appreciate you efforts and insights and rely on them. I have found the information to be very helpful clinically and am personally grateful to you and on behalf of my patients.
Clinical science( and a bit of art/skill in it)has such a variable biological aspects, which cannot be measured accurately,as yet, by the available physical and statistical tools. So till the ‘measuring tools’ are refined/calibrated appropriately, there is nothing wrong in using one’s senses, mind and wisdom to evaluate and apply therapeutic measures.
Clinical science(and a bit of art/skill in it) has a lot of biological variants in it, and as such cannot be accurately measured by physical and/or statistical tools as yet. So it is better to use one’s senses, mind and wisdom, to observe, interpret and apply therapeutic processes. Maybe it is time to refine/devise tools(evidence creating) that match the prudent observations.
Dear kevin thanks for bringing such an indirect diamond advises
which is the need of the day .Really you doing best for our clinician you providing light in darkness and we start move towards the right destination.as you said that i will do research and learn more and more so it is good because there is no limitation and barrier for learning as( King Taimur said try try again you will be succeed ).
Thanks once again for such indirect guidance.
dr tayab khalily
Kevin, Before you hang up your Snake Oil shingle, maybe we can talk about an article from the same journal your article about social media was published in, “Seminars in Orthodontics” (http://www.semortho.com/article/S1073-8746(16)30023-8/pdf)
It’s about Medically Necessary Orthodontic Care (MNOC), by Joe Ghafari from U. Penn and U.Beruit. He’s well published on this topic. And, by the way, this topic is being discussed at the highest levels of organized orthodontics.
Can you cover this article in your next post, please?
Thanks for the comments, I will look at this paper but when I read it, I was not so struck as it appears to be a traditional literature review? Do you think that this is a high level of evidence?
In an ideal world you’re step by step approach to bringing an idea into the mainstream would be ideal Kevin. However anything which threatens the established way of doing things is likely to be resisted or rejected. Take orthotropics for instance. This has helped hundreds of people over the last few decades and is a potentially superior approach to treating malocclusion than orthodontics. This means it is quite a controversial thing to investigate and university based professors/researchers of orthodontics are likely to be too afraid to take it on. They likely feel they won’t receive funding as many of the funding boards are led by orthodontists. So where does that leave us? Well there’s always a chance that someone like yourself will step up and try to make a difference, bust a gut and change the system, but that is rare and risky. So it is left to outsiders to chip away, often for years until eventually the understudied results speak for themselves. After enough members of the public learn about a new approach like orthotropics, particularly when orhtodontics has failed them, demand becomes too great for the establishment to resist and change begins. But it can take years and unfortunately, many people miss out on a potentially greater treatment. This is an issue across all research and new ideas are often rejected for fairly unconscious reasons. I noticed in the last post that you were interested in researching orthotropics. I hope you do this. Your position and experience puts you in a good position to improve the system for good.
Hi Kyle, thanks for the comments. Please do not think that orthodontists have not tried to work with John Mew before on investigating orthotropics. Several of us have tried and this has not worked because the quality of the records that he provides has been so low that it was not possible to analyse them. I have tried on two occasions and given him a platform to present his ideas twice. But this always ends up in disappointment…
Kevin, I mis-spoke earlier when referring to the chapter title in Thinking Fast and Slow and I wanted to clarify for you and anyone else following this discussion. The title of the chapter is actually “Causes Trump Statistics” (Chapter 16). The word “cause” here is used as in the word “because” as in the sentence “The teeth align faster because there is less friction” or “Sleep apnea is more likely in extraction cases because there is less room for the tongue”. Psychologists have found that when there is a visual or intuitive story that is inherent in the “because” statement, our brains are wired to almost automatically accept the story over a different statement that uses only statistics. From the very beginning, the profession of Orthodontics has been guided, or actually misguided, by the tendency to believe the “because stories” that our Guru’s have preached to us starting with Edward Angle’s resistance to extractions “because God gave us 32 teeth”.
As I said, this book and especially this chapter helped me understand much of what is going on in orthodontics today.
John McDonald
The problem as I see it, is that proponents of treatment unsupported by research, still make these claims of “superiority” with zero evidence to support it. And then, when the evidence does not in fact support their claims, they just reject the evidence instead of reassessing their concepts! Case-in-point would the rather well done research paper by Rugh and Larsen that analyzed prevalence of OSA among patients with and without four premolars extracted. There was no difference in the rates of OSA between the two groups. Did these findings change the opinion and rhetoric of those who claim that extractions cause OSA? No, it did not. So, one then has to ask, if individuals make a priori conclusions (such as “superiority over conventional Tx” etc.), would any amount of scientific evidence to the contrary change their minds. A tenet of basic research, is to be unemotional about the results. In these cases, the degree of emotion involved precludes a reasonable scientific debate. As time is our witness, the literature is replete with ideas and concepts that DO NOT WORK, and yet they are being sold and marketed as the latest and the best. The converse is very unlikely.