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Harvard Medical School: Veritas for Sale (Part I)

Several years ago I stumbled upon disturbing information regarding my alma mater, the Harvard Medical School (HMS).† Its professed commitment to investigate implausible medical claims had somehow metamorphosed into the advocacy of such claims. I’ve previously mentioned some of this on SBM (here and here). A couple of pertinent essays appeared in the public domain in 2002 and 2003, but the full story was much more involved than those pieces revealed. In the wake of recent posts on SBM about medical schools exposing students to uncritical portrayals of pseudomedicine, it seems appropriate to tell more of it. I’ve also decided to name names, which is something that I would have been reticent to do a few years ago. The basis for that decision will become clear over the next few posts, I trust. This topic will require at least three posts.

My discovery that HMS had begun promoting pseudoscientific medical claims was occasioned by my experience on the Massachusetts Special Commission on Complementary and Alternative Medical Practitioners, which met from the fall of 2001 to the winter of 2003. Another member of that commission was David Eisenberg, the Director of the Harvard Medical School Center for Alternative Medicine Research and Education (CAMRE) and of the new Osher Center for Complementary and Integrative Medical Therapies. Dr. Eisenberg is best known for his 1993 article reporting the use of ‘unconventional therapies’ by Americans. He had been appointed to the commission by the MA Commissioner of Public Health at the time, Dr. Howard Koh–whom President Obama has recently nominated to be Assistant Secretary of HHS. I assumed then, and still do, that Dr. Koh presumed Dr. Eisenberg to be an objective expert on “CAM,” since that was the persona presented by HMS and by Dr. Eisenberg himself. I had my doubts, but before then I’d not bothered to look into the matter.

It was during commission meetings, when I had the opportunity to hear what Dr. Eisenberg and his surrogate had to say or not to say and when I examined some of their writings and funding sources, that I began to realize how far his project was deviating from what I imagined to be the agenda of HMS. Some of what I saw amounted to frank dishonesty: failure to disclose obvious conflicts of interest to the Commission, for example. I also discovered public promotions of dubious “CAM” practices and practitioners by the CAMRE, in spite of its formal purpose being that of investigating “CAM” practices in an attempt to find out if any might be useful. I was concerned enough to look at other “CAM” information offered in the name of Harvard, and I found more worrisome examples.

I also attended the Feb., 2001 Harvard Complementary and Integrative Medicine Course, directed by Dr. Eisenberg (here is a link to the similar 2002 course brochure). A few of the talks were reasonable, if banal. I did my best to give them the benefit of the doubt, because I still could not accept that HMS would seriously consider homeopathy, ‘life-force,’ and ‘subluxations’ as being worthy of study, much less advocacy. After attending a semi-rigorous talk on raw herbs as medicines (the presenter discussed some studies but not the looming question of why whole herbs might be preferable to purified molecules), I ran into Eisenberg and did my best to be polite and encouraging. I shouldn’t have, because most of the content of the course was misleading and pseudoscientific. Overall, its tone was more like a political rally or a religious revival than a scientific conference.

At that course I ran into Russell Phillips, who had been in my group of interns at the Beth Israel Hospital (Boston) in 1979. I’d seen him around from time to time over the years, and I’d known that he’d stayed on at the BI after his residency. I was surprised, however, to learn that he was now the Director of the Harvard CAMRE Fellowship program. I was even more surprised to learn, during a short conversation with him, that he was innocent of the chiropractic ‘subluxation theory’ and that he’d never heard of Quackwatch. It seemed to me that there was either a surprising naivete among this crowd or an attempt by some to shun unpleasant information.

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Posted in: Medical Academia, Science and Medicine

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Medical Propaganda Films

David Gorski suggested I expand on a comment I left recently on one of his November posts. His subject was the then new documentary movie, “A Beautiful Truth.“ “Truth” is about the Gerson method – the dietary deprivation cum coffee enema cancer treatment developed by Dr. Max Gerson, a refugeee from Germany I the 1930s. His daughter, Charlotte now runs the Gerson Institute in Tijuana, Mexico. Gerson is one of the models for the Gonzales method recently reviewed by Kim Atwood.

I had previously referred to the movie in a prior post (1) (but in a different context. Here I’ll explore the movie from a different angle – with its partners, propaganda documentaries.

David called my attention to “Truth” plus another by the same producer – with trailers on You Tube. When I watched the trailers last year I saw myself interviewed briefly, but could not recall being filmed, or even identify where the scene took place. I had to email Steve Barrett, also in the movie, who reminded me about filmmaker Steve Kroschel’s visits 2-3 years before, although neither did he have strong memory of the interview.
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Posted in: Cancer, Clinical Trials, Energy Medicine, Health Fraud, Herbs & Supplements, Nutrition, Science and Medicine, Science and the Media

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Medical students actively recruited for CAM

Here at Science-Based Medicine we’ve been getting a lot of letters from medical students.  This is a good thing and a bad thing.   I’m glad people see us a a resource for SBM, but I’m unhappy that medical students: 1) need us; 2) don’t have someone to approach on campus.  Let’s explore some of the more subtle ways cult medical practices infiltrate medical education.

Outpatient Rotations

In order to give all of their students experience in outpatient medicine, most med schools must reach out to the community.  Sure, some med schools have big enough clinics to support an experience for all of their students, but that’s the minority.  For their internal medicine, pediatrics, and family medicine rotations, med students often spend time at private doctors’ offices.  These offices are minimally vetted, and I’d venture to guess that the vetting does not include checking for non-standard practices.   In fact, schools are so desperate for spots, that almost any office will do.  It’s good for students to see how medicine is practiced in the “real world” but that real world often involves cult medicine practices.  Along the same lines, many practitioners are not up to date on the most recent best practices.  I remember a family doc I worked with who used to give huge doses of intramuscular steroids to people for seasonal allergies.  This isn’t the best idea, but I was a student. Who was I to tell him how to practice medicine?

We don’t police our colleagues very effectively—we have surrendered that duty largely to the courts.  However, if doctors want a medical school affiliation, it seems a small price to allow the school to come in and see if the office practices medicine  according to the standard of care.  In addition to checking for the most minimal quality standards, it would rule out docs who are offering voodoo in place of medicine.
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Posted in: Medical Academia, Medical Ethics, Science and Medicine

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The kindest cut?

ResearchBlogging.orgThe best way to prevent sexually transmitted infections is the proper use of condoms. That being said, it’s not the only way to prevent STI’s. Abstinence is one way, but it involves an amputation of sorts—the removal of a critical human behavior. Another amputation (of sorts) that prevents STIs is circumcision. Male circumcision has been found in several good studies to reduce the rate of HIV transmission, and now a study out of Uganda shows a significant decrease in rates of genital herpes infections (HSV-2), human papilloma virus (HPV) infection (the strains that cause penile, cervical, and anal cancer), but no decrease in syphilis infection.

This study complements the our knowledge on the benefits of circumcision to prevent disease. The authors emphasize that circumcision alone is not sufficient, but may be a useful adjunct to prevent serious STIs. In fact, STI’s tend to travel together, and ulcerative diseases such as herpes increase transmission of HIV.
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Posted in: Science and Medicine

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Where’s the outrage?

I thank everyone for my warm welcome to the SBM community. Although vaccine myth is of particular interest to me, I promise that my posts wont all be vaccine related. There is, unfortunately, much to discuss. In fact I had a difficult time deciding which vaccine-related issue to write about for my inaugural post. In the end I came up with more of an opinion piece, but it’s an issue worth airing. Things in anti-vaccine land may be reaching a dangerous turning point.


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Posted in: Public Health, Science and Medicine, Vaccines

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When Should We Call A Quack A Quack?

It is not uncommon for Science Based Medicine to receive complaints about the tone of our writing. Some people feel that it is indelicate to use the “q” word (for the uninitiated, “q” is for “quack”) when describing practitioners who promote disproven therapies with jubilant fervor. Others believe it unkind to lump “well meaning” alternative medicine experts in with those who are engaged in overtly illegal activities.

We are all affected by the tension between wanting to call a spade a spade and respecting our cultural need to be polite. Perhaps one of the clearest examples of this inner conflict is Orac’s Respectful Insolence blog. As the name implies, Orac is both thoughtful and brutally honest – he expresses our communal reticence to make waves, but follows up with a reasoned hostility that is quite understandable, given the circumstances described in each post. Respectful Insolence is fun to read because it is educational, persuasive, and expressive – and it captures how many of us feel about various forms of hucksterism. However, snake oil salesmen and their sympathizers are unlikely to enjoy the blog.

Here at Science Based Medicine, readers find a wide range of expression with a common commitment to science and reason. Just as physicians have different practice styles (some are more nurturing in temperament, others offer “tough love”) so too do we authors vary in tone. For those readers who favor one style over another – I hope you’ll find the voice that suits you and return regularly for more. Please don’t assume that one particular post is representative of the entire blog, and please don’t be offended by the legitimate exasperation of writers who have suffered through decades of observing swindlers swindle.
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Posted in: Cancer, Science and Medicine

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Alternative medicine use and breast cancer

Of all the posts I and my cobloggers have written for SBM over the last 15 months, most provoke relatively few comments. However, a few stand out for having provoked hundreds of comments. The very first post that provoked hundreds of comments was Harriet’s excellent discussion of the International Network of Cholesterol Skeptics. In fact, Harriet seems to be quite good at writing posts that provoke a lot of comment, as another of her posts, specifically the one in which she discussed circumcision, also garnered hundreds of comments. However, to my great surprise, the one post that stands out as having received the most comments thus far in the history of SBM is one that I wrote. Specifically, it was a post I called Death by “alternative” medicine: Who’s to blame?, which has collected an astonishing 611 comments thus far. The topic of the post was a case report that I had heard while visiting the tumor board of an affiliate of my former cancer center describing a young woman who had rejected conventional therapy for an eminently treatable breast cancer and then returned two or three years later with a large, nasty tumor that was much more difficult to treat and possibly metastatic to the bone, which would make it no longer even potentially curable. My discussion centered on what the obligation of a physician is to such patients who utterly refuse the science- and evidence-based medicine that we know to be able to cure them of a potentially fatal disease, and I was not only surprised but somewhat taken aback by the vehemence of the discussion.

Since that post, I’ve always been meaning to take a look at what, exactly, the effect of choosing “alternative” medicine over “conventional” medicine is on the odds of survival for breast cancer patients. Even though intuitively one would hypothesize that refusing scientific medicine and relying on placebo medicine instead would have a detrimental effect on survival, it turns out that this question is not as easy to answer as you might think. For example, if you do a search on PubMed using terms like “alternative medicine,” “breast cancer,” and “survival,” the vast majority of the hits will be studies of complementary and alternative medicine (CAM) and breast cancer with little reference to what possible effect these therapies might have on survival. I can envision several reasons for this, the first being that–thankfully–relatively few women actually use alternative medicine exclusively to treat their breast cancer. Also, those that do probably drop off the radar screen of their science-based practitioners, and it is difficult, if not impossible, to capture data regarding their outcomes, given that they all too often stick with their alternative healers until the end. True, they may pop up again in their surgeon’s or primary care doctor’s office with huge, fungating tumors, only to be told that they have to undergo chemotherapy to shrink the tumor before any surgery is possible, after which they will often disappear again. Another important reason is that the natural history of breast cancer is extremely variable, from nasty, aggressive tumors that kill within months to indolent, slow-growing tumors that, even when metastatic, women can survive with for several years. (It is, of course, these women who usually show up in “alternative medicine” testimonials, because they can survive a long time with little or no treatment before their tumors progress.)
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Posted in: Cancer, Herbs & Supplements, Science and Medicine, Surgical Procedures

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CAM on campus: Naturopathy

The latest event sponsored by “integrative medicine” proponents on my medical school campus featured the naturopath “Dr.” PB, a 2003 graduate and valedictorian from Bastyr University. Advertisements all over campus billed the lecture as “Stress, nutrition, and the GI tract,” which seemed innocuous enough. However, the lecture title as written on PB’s slide show was “Naturopathic apologetics for treating the gut.” He explained “treating the gut” to mean that for a wide variety of symptoms the naturopath’s diagnosis inevitibly focuses on the intestine and interventions nearly always involve dietary changes or supplements. Apparently some critics find this preoccupation to be excessive; hence “apologetics,” a word that connotes rational defense of articles of faith. This word choice was appropriate, as the lecturer wove snippets of basic physiology, but never any direct evidence, into a just-so story about how nearly all disease is caused by the modern lifestyle and can be ameliorate with dietary intervention.

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Posted in: Medical Academia, Science and Medicine

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Placebo Therapies: Are They Ethical?

Is it ethical to overstate the efficacy of a treatment option, if it might lead to a patient’s enhanced experience of that treatment? Your response to this question may reveal the degree to which you favor Complementary and Alternative Medicine (CAM). Let me explain.

As far as I can tell, no CAM treatment has been proven effective beyond placebo. (If you’re not convinced of this, I suggest you take a look at Barker Bausell’s book on the subject.) That means that treatments like acupuncture, homeopathy, Reiki, energy healing, Traditional Chinese Medicine (such as cupping), and others (like “liver flushes”) perform about as well as placebos (inert alternatives) in head-to-head studies. Therefore, the effects of these treatments cannot be explained by inherent mechanisms of action, but rather the mind’s perception of their value. In essence, the majority of CAM treatments are likely to be placebo therapies, with different levels of associated ritual.

For the sake of argument, let’s assume that CAM therapies are in fact placebos – the question then becomes, is it ethical to prescribe placebos to patients?  It seems that many U.S. physicians believe that it is not appropriate to overstate potential therapeutic benefits to patients. In fact, the AMA strictly prohibits such a practice:

“Physicians may use [a] placebo for diagnosis or treatment only if the patient is informed of and agrees to its use.”

Moreover, a recent article in the New England Journal of Medicine concludes:

“Outside the setting of clinical trials, there is no justification for the use of placebos.”

However, there is some wavering on the absolute contraindication of placebos. A recent survey conducted by researchers at the Mayo Clinic asked physicians if it was permissible to give a dextrose tablet to a non-diabetic patient with fibromyalgia if that tablet was shown to be superior to no treatment in a clinical trial. In this case 62% of respondents said that it would be acceptable to give the pill.

The authors note:

“Before 1960, administration of inert substances to promote placebo effects or to satisfy patients’ expectations of receiving a prescribed treatment was commonplace in medical practice. With the development of effective pharmaceutical interventions and the increased emphasis on informed consent, the use of placebo treatments in clinical care has been widely criticized. Prescribing a placebo, it is claimed, involves deception and therefore violates patients’ autonomy and informed consent. Advocates of placebo treatments argue that promoting the placebo effect might be one of the most effective treatments available for many chronic conditions and can be accomplished without deception.”

How do you feel about placebos? Are they a legitimate option in some cases, or a violation of patient autonomy and informed consent?
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Posted in: Medical Ethics, Science and Medicine

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Acupuncture – Disconnected from Reality

The primary goal of science-based medicine (SBM) is to connect the practice of medicine to the best currently available science. This is similar to evidence-based medicine (EBM), although we quibble about the relative roles of evidence vs prior plausibility. In a recent survey 86% of Americans said they thought that science education was “absolutely essential” or “very important” to the healthcare system. So there seems to be general agreement that science is a good way to determine which treatments are safe and work and which ones are not safe or don’t work.

The need for SBM also stems from an understanding of human frailty – there are a host of psychological effects and intellectual pitfalls that tend to lead us to wrong conclusions.  Even the smartest and best-meaning among us can be lead astray by the failure to recognize a subtle error in logic or perception. In fact, coming to a reliable conclusion is hard work, and is always a work in progress.

There are also huge pressures at work that value things other than just the most effective healthcare. Industry, for example, is often motivated by profit. Institutions and health care providers may be motivated by the desire for prestige in addition to profits. Insurance companies are motivated by cost savings. Everyone is motivated by a desire to have the best health possible – we all want treatments that work safely, often more so than the desire to be logical or consistent. And often personal or institutional ideology comes into play – we want health care to validate our belief systems.

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Posted in: Acupuncture, Science and Medicine

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