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Pitfalls in Regulating Physicians. Part 1

I had intended today’s posting to be a summary of a real case faced by a state medical board. It is a case of licensed physicians treating patients with a substandard, dangerous, and unequivocally illegal method. My intent was to use it as an illustration of how difficult it can be for medical boards to discipline such practitioners, even when the treatment involved is obviously, blatantly bad. Only yesterday, I was informed by the pertinent board that because this case has yet to be resolved, I may not discuss it. So be it: I’ll save the specifics for another time. Instead I’ll offer a general example of a dubious treatment as a prelude to Part 2 of this series,† which will attempt to discover some of the reasons that medical boards might, under such circumstances, be ineffectual.

Intravenous Hydrogen Peroxide

Hydrogen peroxide (H2O2) is a highly reactive compound that is caustic to living tissues. It spontaneously decomposes to water and oxygen, a reaction that is greatly accelerated in the presence of peroxidases (mainly catalase), which are ubiquitous in human blood and tissues. It has been used as a disinfectant for superficial skin wounds and in the mouth, and also for fabric and medical equipment. It has been used as a bleaching agent for teeth and hair. When used as an irrigant in surgical fields, in other large wounds, or consumed in any form (including intravenously), however, it has resulted in predictable, catastrophic complications: arterial and venous gas emboli, emphysema, respiratory arrest, strokes, multiple cerebral infarcts, seizures, colonic ulcers, intestinal gangrene, acute hemolytic crises, shock, cardiac arrest, and death.[1-7]

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Prepare for Surgery, Heal Faster?

Quacks and their apologists often cite surgery and emergency treatments of traumatic injury and a few other catastrophic or potentially catastrophic events as the only ”conventional” or “allopathic” methods that they consistently recommend. Explicitly or implicitly, for most problems they tout “holistic” or “CAM” treatments. In modern medicine, however, there are plenty of non-surgical and non-emergency treatments whose outcomes are so manifest that even the most exuberant advocates of implausible medical claims (IMC) seem careful to steer clear, lest they blow their cover. Where are the promoters or consumers of homeopathic contraceptives? Why haven’t we heard of a chiropractic adjustment for high blood sugar? How many pitches for Ayurvedic treatments of gout have you seen? There are exceptions, of course, the most notable being the nearly ubiquitous anti-immunization stance among IMC promoters.

Anesthesiology and Implausible Claims

In my day job I specialize in anesthesiology, a non-surgical field whose methods are so obviously effective that little is heard from the IMC crowd. Consider: is it likely that even the slickest of the current crop of snake oil salesmen, if they had the bad sense to try, could talk many people into accepting an implausible method for rendering the body insensible to pain? No, that would require a more effective form of persuasion, such as that used in China to promote “acupuncture anesthesia” from the mid-1950s until the end of the Cultural Revolution in 1976. That’s a story I’ll tell another time.

A few other implausible claims have crept into the broader realm of anesthesiology. Stimulation of the “pericardial 6″ acupuncture point on the ventral aspect of the wrist is said to prevent post-operative nausea. There is little basis for this, the Cochrane Review notwithstanding. Verbal messages, given to a patient under general anesthesia, are said to result in “faster healing.” The major proponent of this claim is Peggy Huddleston, a self-described psychotherapist with an M.T.S. (Master of Theological Studies) degree from the Harvard Divinity School. Ms. Huddleston appears to have parlayed the “faster healing” claim into a successful entreprenurial venture, featuring a website, workshops, CDs, and a book:

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“Patient-Centered Care” and the Society for Integrative Oncology

Should Medical Journals Inform Readers if a Book Reviewer can’t be Objective?

At the end of last week’s post I suggested that book reviewer Donald Abrams and the New England Journal of Medicine had withheld information useful for evaluating Abrams’ review: that he is the Secretary/Treasurer of the Society for Integrative Oncology (SIO), the organization of which Lorenzo Cohen, the first editor of the book that Abrams reviewed,* is President. I also promised to look at material from the book and from the Society’s website in order to discover “data that will allow even the most conventional oncologists to appreciate [the value of 'integrative' methods].”

There is little question that Abrams and Cohen know each other, or at least that Abrams couldn’t have been expected to write an entirely objective review of Cohen’s book. Abrams is the Program Chair for the Society’s upcoming 5th International Conference, sponsored by the American Cancer Society. He and Cohen will be sharing the stage for the “Intro/Welcome.” Does it matter that most NEJM readers wouldn’t have learned of this association by reading the review? Probably not, in the case of readers who are well-versed in the misleading language of “CAM.”

I believe that most readers of medical journals are not so sophisticated. Otherwise, how could it have been so easy for “CAM” literature to seep through the usual evaluative filters, not only in medical schools and government but in the editorial boardrooms of prestigious journals? For anyone from the Journal who might be following this thread, Dr. Sampson’s satirical but deadly serious account of “how we did it” is obligatory reading.

Do “Integrative Oncology” Methods have Value?

Now let’s take a look at what Dr. Cohen’s book and the SIO are up to. The book’s introduction and table of contents are available on Amazon.com. The introduction contains the usual, misleading assertions and falsehoods that are ubiquitous in “CAM” promotions. I’ve added a few hyperlinks:

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Posted in: Book & movie reviews, Cancer, Energy Medicine, Medical Ethics

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The New England Journal of Medicine Disappoints

On July 31 of this year, a collective groan could be heard emanating from critics of pseudomedicine. The causative factors (which is medical bombast for “the cause”) were two book reviews published in the usually staid New England Journal of Medicine (NEJM):

Integrative Oncology: Incorporating Complementary Medicine into Conventional Cancer Care

Edited by Lorenzo Cohen and Maurie Markman. 216 pp., illustrated. Totowa, NJ, Humana Press, 2008. $79.95. ISBN 978-1-58829-869-0.
Reviewed by Donald I. Abrams

Alternative Medicine? A History

By Roberta Bivins. 238 pp., illustrated. New York, Oxford University Press, 2008. $35. ISBN 978-0-19-921887-5.
Reviewed by Teresa L. Schraeder

The Wooification of Medical Journals

I’ll review the reviews, but first let’s consider why their presence in the NEJM is so disturbing. The NEJM is the most widely read and cited medical journal in the world. Among American journals, the top three are usually reckoned to be the NEJM, the Journal of the American Medical Association (JAMA) and, at least for internists, the Annals of Internal Medicine (Ann Int Med). The extent to which each journal has sacrificed its integrity for the promotion of the recent wave of pseudomedicine has varied among the three: the NEJM rarely and, for the most part, unwittingly; JAMA famously in 1998 and occasionally since; and the Ann Int Med repeatedly and embarrassingly, most notably with a series of puff pieces on “CAM” that spanned several years and violated the Annals’ own policies regarding funding disclosures by authors and editors.

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Posted in: Book & movie reviews, Cancer, Medical Academia

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Science, Reason, Ethics, and Modern Medicine, Part 5: Penultimate Words

My Discussion with Dr. P

After last week’s post, Dr. Peter Moran answered with more salient points. I’ll spend this week discussing those, because I share Dr. Moran’s “interest in examining the kind of messages we are putting out.” Acknowledging the inequality inherent in his not being the blog author, I’ll offer the last word to Dr. Moran by ending this series* and letting whatever comments he may have in response to today’s post be the last, at least for now.

Here is Dr. Moran’s response to my response:

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Posted in: Medical Ethics, Politics and Regulation, Science and Medicine

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Science, Reason, Ethics, and Modern Medicine, Part 4: is “CAM” the only Alternative? And: the Physician as Expert Consultant

Dr. Moran Weighs In

In last week’s post, I dubbed Dr. Peter Moran the “conscience” of SBM, citing his commitment to doing what’s best for individual patients even if, in theory at least, that may involve some manner of benign but fanciful treatments. I countered with my own opinion that honesty and integrity are necessary parts of any discussion with a patient, and that they, in turn, must not conflict with science and reason.* I added passages from a couple of key medical ethics treatises to support my assertion. Dr. Moran’s response, thoughtful and provocative as always, was buried in the midst of other commenters’ tangential arguments about the theory of evolution. Rather than continue its exile there, I reprint it here to give it the exposure that it deserves:

A blatant appeal to authority, but one that I mostly agree with. The difference between us is that I insist that medicine is about an infinite number of individual contexts and I see many examples where ethical absolutes (actually these are ethical guidelines rather than directives) do not apply or don’t seem to apply very well.

We scientists are ever-so cautious when making scientific judgments about complex matters; let’s not pretend that arriving at absolutes in medical ethics is a piece of cake, especially when it is not quite clear how anything done with the undiluted welfare of the individual patient in mind can be entirely unethical. I mean, why are we obliged to consider the impact of our decisions upon the fate of the planets (or whatever) when THIS patient needs help? In fact, at least one medical ethicist has gone so far as to state that it is not unethical for a doctor to prescribe a placebo treatment, so long as the doctor believes it will benefit the patient. I don’t quite agree with that bald statement — there should be a rider specifying that this may apply to *some* contexts where there is no obviously superior evidence-based method.

Here are some examples of the intellectual minefield we have to negotiate.

1. All the doctors I know would be prepared to call in the witch-doctor if it would help assuage the fears, or help in the management, of a seriously ill primitive tribesman. It seems we are prepared to pander to the superstitions of SOME cultures while despising any similar inclinations in our own.

2. I have previously asked this question which has to do with public policy in relation to safe “alternatives”. Take my word for it that every pharmacy in Europe displays “Homeopathie” (or language equivalents) in large letters outside. Would skeptics prefer those using such remedies for their minor and self-limiting complaints to be using NSAIDs or antibiotics or antidepressants instead, treatments that will often in such contexts themselves perform no better than placebo, but at substantially greater risks? Behind the usual healthfraud position there is both an exaggeration of the capacity of modern medicine and insufficient recognition of the harm that it can do. We definitely do not yet have entirely safe and 100% effective solutions to all of mankind’s ills, and certain imperfections of everyday medical practice can heighten the risks of the use of unnecessarily powerful pharmaceuticals. So what is the safest and most pragmatically realistic position here?

3. Following on from that — what is the evidence-based answer to non-specific tiredness and unhappiness? If people feel better for taking a multivitamin or an innocuous herb, why should we care? We keep on offering the public temporary answers to these things, prescribing (historically) amphetamines, cocaine, opiates, barbiturates and phenothiazines in massive quantities, only to take them away when problems such as addiction ensue. Is it right to then turn around and say, well you didn’t really need these things anyway, even denying them any relief that they may derive from “pretend medicines”. The science that matters will be argued out in other arenas.

That’s to give you some idea of the kind of thing that I am on about. You seem to think I am talking about doctors promoting CAM or placebo treatment as a matter of policy. I am not prepared to go that far, although I think I understand why some doctors might do that.

I agree that “medicine is about an infinite number of individual contexts and [there are] many examples where ethical absolutes do not apply or don’t seem to apply very well.” Nor did I really think that Dr. Moran was “talking about doctors promoting ‘CAM’ or placebo treatments as a matter of policy.” We disagree elsewhere, but he makes some interesting points.

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Science, Reason, Ethics, and Modern Medicine, Part 3: Implausible Claims and Formal Ethics Statements

The Ethics of Implausible Medical Claims (IMC)

In Part 2 of this series* we learned from David Katz, MD, a key member of the Yale School of Medicine’s “integrative medicine” program, that he had been “pushed toward integrative medicine by the needs of [his] patients.” We also learned that Dr. Katz’s rationale for this decision justifies a wide range of quackery—both in principle and in fact. I had previously alluded to arguments like those of Dr. Katz in a comment on SBM several months ago:

…we must be true to medical ethics, no matter what else we do. If that means losing a few patients, so be it. Patients are free agents, and we can only do so much to influence them. To the extent that we don’t do that as well as we might (which is obviously true in some cases), we might do better. But our ethical obligation is to science and truth; it is not, as many modern physicians would have it and as much as we may lament sometimes losing patients to woo, to seducing patients to stick with us no matter what, if the “what” includes engaging in a charade about “integration” or “complementary therapies”…

Realizing that some might argue that physicians’ obligations to patients ought to trump their obligations to “science and truth,” I later revised that statement:

Several weeks ago I argued here that a physician’s primary ethical obligation is to science and truth. In retrospect I probably should have put it a slightly different way: a physician’s primary ethical obligation is the same as everyone else’s. It is to honesty and integrity. For physicians, however, that means being true to real medical knowledge, among other things, and real medical knowledge comes from science.

In spite of that revision, two readers whose opinions I respect challenged my assertion. Dr. Peter Moran’s worthy efforts to educate patients about the realities of “alternative” cancer treatments are considerable. Here on SBM he has repeatedly challenged us to explain how, when confronted with testimonials of “alternative” cures, we ought to respond without using “a high-handed, ‘we know best’ stance” and thus “appear to want to distance [ourselves] from the intimate concerns of [our] patients.” I was thinking mainly of him when I wrote the revision above, because on this key topic—how to respond ethically, but with compassion, to patients who want to believe in implausible treatments—I’ve come to think of Dr. Moran as the “conscience” of Science-Based Medicine. Those with cancer, he has reminded us, “are folk very like you and me who are simply grasping at any straw that might save or prolong their lives.” His take on why IMCs are appealing to those with less ominous problems is well-developed and agrees with my own, mostly. We part ways, however, when he concludes (also here and here) that ethical physicians might have good reasons—unlike Dr. Katz’s—to entertain benign, if implausible treatments:

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Science, Reason, Ethics, and Modern Medicine, Part 2: the Tortured Logic of David Katz

In Part 1 of this series* I asserted that a physician’s primary ethical responsibility is to honesty and integrity, which in turn must be largely based on science and reason (I apologize if that sounded preachy; if there had been more time I might have couched it in more congenial terms). I mentioned the fallacious reasoning whereby proponents of implausible medical claims (IMC) point to real and imagined weaknesses of modern medicine to justify their own agenda. I offered, as a favorite example of such proponents, science-based medicine’s having not yet solved every health problem. This week I’ll show how this version of the tu quoque fallacy has led a prestigious medical school to advocate pseudoscience-based medicine.

Modern Medicine: a Brief, Fragile Commitment to Science

First, a few more words about the title of this series. Modern medicine is not science, even if it draws upon science for its knowledge: it is an applied science similar, in that sense, to engineering. Modern medicine is also not synonymous with the “medical profession,” if the term means the collection of all people with MD degrees. That is true for the obvious reason that medicine is more than people, but also because a small but loud minority of MDs rejects modern medicine and science.

Modern medicine has made an uneven commitment to science and reason. At its best, it has formally embraced them in the faculties and curricula of medical schools, in its codes of ethics, and in its contributions to knowledge, both basic and applied, over the past 150 years or so. As discussed last week, it is because of science and reason that modern medicine has made dramatic, revolutionary advances in a very short time. That is what distinguishes it from every other “healing tradition,” and why there is no legitimate competition. The only valid medicine in the modern world is science-based medicine—not “allopathic,” “Western,” “conventional,” “regular,” “integrative,” “complementary and alternative,” or any of the so-called “whole medical systems.” The pre-scientific (and, ironically, “post-modern”) designation of “schools” or “systems” of medicine, so stridently trumpeted by quacks, is an anachronism—even if it persists in archaic, governmental edicts.

Compared to the actual sciences, however, modern medicine’s commitment to science is fragile. Its recent confusion of error-prone clinical trials with science itself—the project called “evidence-based medicine”—has been a mixed blessing. Its growing tolerance of charlatans and crackpots, at times elevating them to celebrity status, would be unthinkable in physics or biology. Its dalliances with quackery, so depressingly recounted in recent posts here, here, here, and here, are why your SBM bloggers do what we do. Biologists, other scientists, and intellectuals in general have joined the battle against the pseudoscientific travesty known as “intelligent design.” Many physicians, however, even of the brainy, academic variety, act as though the equally pseudoscientific but more dangerous travesty known as “integrative medicine” is either a good thing or, at least, is a necessary addition to medical school curricula.

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Science, Reason, Ethics, and Modern Medicine Part 1: Tu Quoque and History

Several weeks ago I argued here that a physician’s primary ethical obligation is to science and truth. In retrospect I probably should have put it a slightly different way: a physician’s primary ethical obligation is the same as everyone else’s. It is to honesty and integrity. For physicians, however, that means being true to real medical knowledge, among other things, and real medical knowledge comes from science. That is what this and the next several posts will be about.*

First, a little Tu Quoque

After reading some of the comments that followed my posting of two weeks ago, I reluctantly thought to add a few words about the medical profession’s view of physicians selling drugs. It felt tiresome to have to address the issue, because it is beside the point. The series was about “naturopathic medicine,” not about modern medicine. If readers who understand the point will excuse the interruption, I’ll quickly attempt to explain why by posing two extreme possibilities: If MDs are entirely innocent of the relevant breach of ethics, what would that have to do with naturopaths selling drugs? But if MDs are entirely guilty, two wrongs don’t make a right—demonstrating the same irrelevancy.

That is why the ”you should talk” sneer is known, in debate, as the tu quoque (“you too”) fallacy. It’s funny how parents seem to recognize it when faced with children who, in seeking permission to engage in dubious activities, invoke the parents’ own sordid histories or the equally irrelevant, alleged prerogatives of other people’s children. Yet the same parents appear to forget it in other contexts.

I was also weary and wary of those who would draw me into a strawman debate pitting the medical profession against any group of sectarian health advocates. I have only a small sense of “solidarity” with the group of people who have MD degrees, and even less so with organized medicine. My first allegiance, as I’ve explained elsewhere, is to science and reason. Those modes of inquiry, together with their obvious bearing on the integrity of all claims about nature, are the bases for my objections to naturopathy and to pseudoscience in general. The medical profession per se is related but not central to the issue. While thinking about these things, it dawned on me that a discussion of why that is might be useful. (more…)

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Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 4

The “Science” and Ethics of “Natural Medicines” (and Nutrition) cont.

This is the continuation of a discussion concerning the explicit claim of “naturopathic physicians”* to being experts in the use of “natural medicines,” defined as “medicines of mineral, animal and botanical origin.” Last week’s post established that the cult has chosen to profit from the “retail selling of medications,” as evidenced by the relevant Position Paper of the American Association of Naturopathic Physicians (AANP) and by that organization’s having made a deal with a drug company to make profits for both itself and its members.

The Position Paper observes that such selling “could be construed as a conflict of interest on the part of the physician.” That is true, if embarrassingly understated: anyone representing himself as a physician, who both recommends and sells the same medications for a profit, has conflicting interests. The conflict undermines his claim to offering responsible advice regarding those medications, and as such is a breach of medical ethics.

The AANP’s deal with MotherNature.com was even worse: by promoting such peddling in a formal, institutional fashion, NDs and their national organization went beyond the already widespread problem of practitioners hawking drugs. It is unclear whether the deal still exists, by the way: MotherNature.com was a victim of the “dot com” bust of a few years ago. It has since been resurrected, but a quick perusal of its new website fails to reveal the old AANP relationship. Nevertheless, I have seen no evidence to suggest that the AANP has changed its view of that sort of deal.

Are NDs Truly “Learned Intermediaries” in the Use of “Natural Medicines?”

This entry discusses the other part of the claim of expertise: that, aside from their conflicting interests, NDs have real knowledge of “natural medicines.” It will become clear during the discussion that the purported naturopathic expertise in nutrition—another standard claim—is also under review. I will include or cite abundant evidence for my assertions, because I’ve found that a predictable response of representatives of the highest levels of “naturopathic medicine” is to flatly deny them. I apologize again for including excerpts from previously published material.

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