The Brown M&M’s of Science-Based Medicine

David Lee Roth. Quality Guru.

Medicine is constantly changing, and like most health professionals, I am required to maintain my competency to practice. I doubt pharmacists are unique in being inundated with offers of continuing medical/pharmacy education. Some courses are free, some cost hundreds of dollars, and it can be difficult to distinguish the high-quality programs from the biased or low-quality education that furthers a agenda, rather than seeking to truly educate. You can consider the reputation of the provider, or the author, and sometimes the sponsorship gives a clue. When it comes to determining if a program’s content is science-based or not, I find the learning objectives may be all I need to read. One program I saw recently referred to “integrative” approaches to the treatment of an illness. Another claimed it would teach you a  “holistic” approach to managing complex medical condition. Both programs set off skeptical alarm bells. I realized then I’d found the science-based medicine equivalent of a brown M&M. And I have the band Van Halen to thank for that association.

No brown M&Ms

I’m a child of the 1980s. Neon fashions. Big hair. It was an era when rock music, preferably played on cassette, on a boom box, was king. And for much of the 1980s, there probably no bigger rock bank than Van Halen. With the amazing guitar work of Eddie Van Halen and the showmanship of lead singer David Lee Roth, Van Halen made heavy metal party music. The album that catapulted Van Halen to 80’s rock gods was their album, 1984. It was a smash hit. The videos were outrageous. Van Halen was pretty much every 1980s rock caricature you could think of. They rocked hard, they partied harder.

Van Halen concerts filled stadiums and were over-the-top, onstage and backstage. As one of the world’s biggest groups at the time, a Van Halen concert was a massively complex sound and lighting show, requiring a fleet of transport trucks to carry everything from city to city. True to their reputation, their list of demands from concert promoters grew and grew. Contracts had dozens of riders, outlining not only highly technical requirements for the shows but a long list of perks for the performers. Van Halen apparently had a reputation for making absurd demands – because they could. Buried deep in the concert rider was one demand that seems too ridiculous to be true.

There were stories of what happened when promoters didn’t follow this request. David Lee Roth, if he found a bowl of M&M that didn’t meet their specifications, had a reputation for trashing dressing rooms. And while this might sound like the height of rock star ego, there was a very specific reason for burying a demand for M&M’s deep in the back of a concert contract.

It was a quality control measure.

The M&M demand had been placed there deliberately by the band to ensure that the promoter had read through the entire contract and fulfilled it in its entirety. If the request had been ignored, the band apparently insisted on a complete check on all other aspects of the production. From David Lee Roth’s biography, via Snopes:

So, when I would walk backstage, if I saw a brown M&M in that bowl … well, line-check the entire production. Guaranteed you’re going to arrive at a technical error. They didn’t read the contract. Guaranteed you’d run into a problem. Sometimes it would threaten to just destroy the whole show. Something like, literally, life-threatening.

Rather than representing enormous rock star ego, the M&M clause was a quick and visible test that verified the promoter was taking the technical requirements seriously.

The brown M&M’s of Science-Based Medicine

Back to science and medicine. The SBM equivalent of a brown M&M is anything that is a warning sign for pseudoscience, or simply a lack of critical thinking. It’s a sign you need to dig deeper. If I was considering registering for a continuing education program in HIV or transplant (two areas that I lack any current experience in), I lack the expertise to determine if the content is of high quality. But if that program makes a positive reference to “complementary and alternative” approaches, then that’s a signal I need to look more closely and critically at all of the content that’s presented.

In hindsight, I realize I’ve done a form of the M&M test with health professionals, too. Years ago I was looking for a family doctor and met with a physician who was known to the local pharmacy I worked at. After some general discussion of health issues, I asked him for his opinion of homeopathy, since I’d noticed many of his patients tended to use it. His response was optimistic – he’d “seen results.” I realized on the spot that I didn’t want him as a family doctor, because if he was fooling himself with homeopathy, I didn’t think I could trust him with guiding my health care decision-making.

You can try a similar test with your pharmacist. Most retail pharmacists have no input into what’s sold on a pharmacy’s shelves (a topic for another day). But seeing something like homeopathy on the shelf is an excellent opportunity for dialogue. Ask them if homeopathy works. If the answer is anything but “placebo effects”, then that’s your brown M&M. If a pharmacist isn’t frank with you about the ineffectiveness of homeopathy, or hasn’t taken the time to understand the science, then you might want to rethink the pharmacy you support.

Here’s an incomplete list of words that, in the right context, are the SBM equivalent of an brown M&M. The mere appearance of any of these words doesn’t necessarily mean there’s a problem. But it’s a signal that you need to proceed carefully:

• biomedical
• holistic/wholistic
• integrative/integrated (though the latter is preferred over the former)
• complementary and alternative
• “functional” medicine
• natural
• quantum

There are probably dozens more – list any of your triggers in the comments, and I’ll add them to the list.

Conclusion: Quality health care is in the details

Details matter. Science matters. All of the contributors to the blog donate their time for the same reason: We want to promote good medicine. Pseudoscience compromises and pollutes good medical care. Rock band Van Halen inserted an absurd food demand deep in a concert rider. It was easy to ignore. Brown M&M’s were their “red flag” for potentially more serious problems that might otherwise go unnoticed or ignored – until they caused harm. For that same reason we regularly document the problems of pseudoscience that masquerades as medicine. Homeopathy may seem harmless until someone dies from substituting it for real medicine. “Complementary” and “alternative” approaches to health may sound low-risk until it leads to ignoring real medicine. The best medicine means a relentless focus on the quality of care. If health professionals don’t take the science and evidence standards of that care seriously, who will?

For a whole day of Science-Based Medicine, join us at NECSS next month, where you’ll learn new brown M&M terms, like “Functional Medicine” and “Chronic Lyme”.