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Doctors Are Not “Only Out to Make Money”

There’s an old joke about the doctor whose son graduates from medical school and joins his practice. After a while the son tells his father, “You know old Mrs. Jones? You’ve been treating her rash for years and she never got better. I prescribed a new steroid cream and her rash is gone!” The father responds, “You idiot! That rash put you through medical school.”

That’s a joke. It doesn’t reflect reality, but it reinforces a common misconception that doctors care more about their own income than about their patient’s outcome. That accusation is demonstrably untrue.

I’m sick and tired of all the doctor-bashing. They accuse us of being shills for Big Pharma. They say “Doctors are only out to make money.” Or “Doctors are greedy bastards only interested in the bottom line.” Or as one of our commenters recently put it: “First do no harm. Second ? Third, profit [sic]” Some have even made the ridiculous accusation that doctors have found the cure for cancer but have suppressed the information so as to keep people sick and increase their business. If profit were really their primary motivation, doctors would have to be astoundingly clueless, because they keep doing things that are guaranteed to reduce their profits.

Those who have already made up their minds that doctors are mercenary can always find plenty of examples to reinforce their belief: confirmation bias works really well to support preconceived beliefs. But if you want to ask whether a claim is true, the trick is to look not for confirming examples but for disconfirming ones. I don’t deny that there are bad apples in the medical barrel, but they are vastly outnumbered by the overwhelming weight of disconfirming examples.

In a recent post, Dr. Crislip describes medicine as “a calling” and explains that he is motivated by compassion. His criticisms of alternative medicine are clearly not based on any fear that CAM will cut into his bottom line, but by the distress he feels when a patient dies unnecessarily, as in the example he gives. Like the majority of doctors today, Dr. Crislip works for a fixed salary: his income does not depend on his decisions about treating patients. I practiced medicine in the Air Force, where nothing I did could have any impact on my paycheck. Even when doctors are in private practice, I think it would be hard to find one so cynical that he would do an unnecessary C-section just because his kid needs braces. And if he did many unnecessary surgeries, he would only expose himself to malpractice lawsuits and to chastisement by hospital management and/or medical boards.

Medicine is not a good way to get rich

People who go into medicine because they want to help people, not because they want to have a multimillion-dollar house, membership in a posh country club, and drive a Porsche. Medicine is not a good way to get rich. To repeat what I said in a previous post, medical education is long, grueling, and expensive. Most doctors incur substantial debts for their education and need many years to repay them. The nice houses and cars don’t come until long after graduation. The median net worth for physician households is $700,000 and their median income is going down. The ones who really get rich are those who market bogus remedies or spread misinformation (like Dr. Oz, Andrew Weil, Stanislaw Burzynski, Daniel Amen, Kevin Trudeau, and all the companies that sell diet supplements and miracle weight loss aids). For comparison, the average net worth of American families is $120,000, and the median net worth of the top half of one percent is $1.8 million. According to one financial analyst, “Membership in [the top half of a percent] is likely to come from being involved in some aspect of the financial services or banking industry, real estate development involved with those industries, or government contracting. Some hard working and clever physicians and attorneys can acquire as much as $15M-$20M before retirement but they are rare.”

Doctors consistently act against their own financial interests

Individual doctors may try to increase their income, but the medical profession as a whole is constantly doing things that tend to decrease provider income while improving patient outcomes. Doctors would surely make more money if they stopped vaccinating and could treat all those patients who would contract preventable diseases. They could charge for more office visits if they ignored the recommended vaccine schedule and delayed and spaced out the injections. They would undoubtedly make more by doing annual routine Pap smears on every woman and executive physicals with chest x-rays, EKGs, and treadmill tests than they can by following consensus recommendations.

If you’re old enough, you will have noticed that doctors no longer do many of the things they used to do when you were a kid, like routine annual urinalyses, TB tine tests, and chest x-rays. Why do you think they stopped? They could make more money if they still did those things and charged for them. Most doctors today do not automatically treat every ear infection with antibiotics, do not offer antibiotics for common colds, and they treat bladder infections with 3 days of antibiotics instead of longer courses. If you believe they are Big Pharma shills, you can only conclude that they are incredibly incompetent ones: shills ought to be maximizing the use of antibiotics and other prescription drugs, not cutting back.

Mainstream medicine has a long track record of re-evaluating its practices and discarding those that have not proven effective. In a recent post Dr. Gorski mentioned “Choosing Wisely,” an initiative of the American Board of Internal Medicine. Its goal is to help patients and doctors choose care that is supported by evidence, low risk, truly necessary, and doesn’t duplicate other tests or procedures. It asked national medical specialty organizations to identify five tests or procedures commonly used in their field whose necessity should be questioned and discussed. The resulting lists of specific, evidence-based recommendations were published in the Archives of Internal Medicine and are available online.

The American Academy of Dermatology list includes:

  1. Don’t prescribe oral antifungal therapy for suspected nail fungus without confirmation of fungal infection
  2. Don’t perform sentinel lymph node biopsy or other diagnostic tests for the evaluation of early, thin melanoma because they do not improve survival
  3. Don’t treat uncomplicated, non-melanoma skin cancer less than one centimeter in size on the trunk and extremities with Mohs micrographic surgery
  4. Don’t use oral antibiotics for treatment of atopic dermatitis unless there is clinical evidence of infection
  5. Don’t routinely use topical antibiotics on a surgical wound

The American College of Physicians list includes:

  1. Don’t do screening exercise EKG testing in patients who are asymptomatic and at low risk for coronary heart disease
  2. Don’t do imaging studies in patients with non-specific low back pain
  3. In the evaluation of simple syncope with a normal neurological examination, don’t do brain imaging (CT or MRI)
  4. In patients with low pre-test probability of venous thromboembolism, do a high-sensitive D-dimer test rather than imaging studies as the initial diagnostic test.
  5. Don’t do pre-op chest x-rays unless there are symptoms of heart or lung disease.

There are 46 of these lists. Each can be easily accessed by clicking on a link. They all make for interesting reading; but if you don’t want to bother, these two examples give you a good idea of what they are like. They address things that some doctors are still doing in the face of clear evidence that they shouldn’t. It always takes time for research findings to be translated into changing practices in the typical doctor’s office, and this is an effort to speed up the process. The goal is to improve patient care, not to boost physician income; in fact, almost everything on the lists is actually at odds with the financial interests of physicians.

The American Academy of Family Practice was not content to list only 5; they came up with this list of 15 items:

  • Don’t do imaging for low back pain within the first six weeks, unless red flags are present
  • Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement
  • Don’t do DEXA screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors
  • Don’t order annual EKGS or any other cardiac screening for low-risk patients without symptoms
  • Don’t do Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease
  • Don’t schedule elective inductions of labor or C-sections before 39 weeks gestation
  • Avoid elective induction of labor between 39 and 41 weeks gestation unless the cervix is favorable
  • Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients
  • Don’t screen women older than 65 for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer
  • Don’t screen women younger than 30 years of age for cervical cancer with HPV testing alone or in combination with cytology
  • Don’t prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable
  • Don’t do voiding cystourethrograms (VCUG) routinely for the first febrile urinary tract infection in children aged 2-24 months
  • Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam
  • Don’t screen adolescents for scoliosis
  • Don’t require a pelvic exam or other physical exam to prescribe oral contraceptives

Please note that for almost every item on these lists, compliance will reduce the use of drugs, screening tests, and procedures. Think about it. What would you expect to see if doctors were really only out to make money? They could conceivably invoke the precautionary principle to justify continuing any of these practices. Why not put all kids with ear infections on long-term antibiotics to prevent recurrences? Why not give long courses of antibiotics for every bladder infection or put patients with recurrences on constant antibiotic therapy “just in case”? Why not do ever-more screening tests and physical exams at more frequent intervals? Why not do more procedures instead of fewer? Once doctors had adopted any kind of test or treatment, why would they ever want to stop doing them and give up the opportunity to get paid for them? C-sections are lucrative: obstetricians could make more money if they stopped doing vaginal deliveries altogether. Thank goodness we don’t see that kind of thing happening in mainstream medicine. We are not seeing promotion of unnecessary tests and treatments that would increase physician income; we are only seeing efforts to improve patient outcomes and rational use of resources.

A stark contrast with the situation in the world of CAM

Contrast science-based medicine’s consistent track record of re-assessment and improvement with the track record of any kind of alternative medicine. I have looked hard for any example of a diagnostic or therapeutic practice that has been tested, found not to work, and systematically rejected by organizations of acupuncturists, homeopaths, or chiropractors. BJ Palmer’s “nerve tracing” technique is no longer being used by chiropractors; but I don’t think there was ever any testing or any “official” rejection, and that’s the only example I’ve ever been able to find.

It would be refreshing to find recommendations by chiropractors for all chiropractors to stop treating infant colic with spinal manipulation, or by acupuncturists for all acupuncturists to stop needling a certain acupuncture point because it had been tested and shown not to correspond to the organ they once thought it did, or by homeopaths for all homeopaths to stop using “Oscillococcinum” because no such organism ever existed. I don’t expect to see any such developments any time soon. If there are any initiatives by a CAM board comparable to the “Choosing Wisely” initiative of the American Board of Internal Medicine and intended to stop diagnostic and treatment methods that have been found ineffective, I sure haven’t been able to find them.

If you want to see an example of blatant efforts to increase provider income without regard to scientific evidence or patient outcomes, there is no better place to look than the typical chiropractic practice-building websites. One website is heavy on advice to welcome patients, call them by name, pay compliments, thank them for referrals, add massage therapy as a new profit center, etc. Another offers these 6 steps for building a profitable practice:

  • Define a niche market, like treating new mothers after the birthing process
  • Market, market, market
  • Run interoffice referral campaigns
  • Network
  • Never back down
  • Be innovative

I’ve looked at a lot of chiropractic practice-building initiatives and I have yet to find any recommendation to improve patient care by stopping ineffective practices. Chiropractors can get CME credits for these science-free income-boosting programs.

Conclusion

The accusation that doctors are motivated solely by money is demonstrably untrue. Most doctors are committed to doing what is in the best interests of the patient regardless of the effect on their income. As new evidence becomes available, they are constantly changing their practices to eliminate the unnecessary and the ineffective. The contrast with CAM providers is striking.

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262 thoughts on “Doctors Are Not “Only Out to Make Money”

  1. Bryan says:

    Thanks HH, great post.

    Lots of people complain they don’t get diagnosed with B12 deficiency by those greedy doctors, who are only trying to keep them unhealthy for as long as they can. Or, if they do get diagnosed, why won’t their doctor prescribe daily injections for maintenance in stead of once a month, if that’s what they feel they need? And why not methylcobalamin, in stead of cyanocobalamin or hydroxocobalamin? Can’t be a lack of evidence, of course. Must be because more money is to be made by denying patients the treatment they know will restore them to full health. How do they know? They went to Google University…

    I always like to point out how doctor Minot and doctor Murphy, publishing their liver therapy in 1926, effectively put the treatment of pernicious anemia, fatal until then, in the hands of butchers.

  2. Stephen H says:

    Actually, I can think of one doctor whose actions were entirely motivated by profit, and who was a “pharmaceutical shill”. Although he is no longer licensed to practice, Andrew Wakefield wanted to replace the existing product with his own patented measles vaccine.

    He then falsified tests in pursuit of profit, and created a mythical link between vaccines and autism that is still believed by some. Evil.

    Of course, there are other doctors whose actions seem motivated by profit rather than better patient care. Doctor Oz is one. Doctor Burzynski, if he cared about patients, would look at evidence.

    Most puzzlingly, the links between people promoting “alternative” medicine (quackery) and the products they push is an awful lot closer than the link between my GP and prescription medications. So why do qualified medical practitioners get accused of being “shills” by the people who really are shills?

  3. Lawrence says:

    Quacks have no interest in “proving” that their treatments work (because actual clinical trials would show they don’t). Someone like Burnzynski can continue to claim whatever he wants, because as long as it doesn’t produce real evidence, he is under no obligation to provide the truth…..

    He can continue to claim that he is being “persecuted” despite the fact that he’s been allowed to make millions of dollars in personal profit over the past 35 years…..

  4. windriven says:

    Apropos of the lists you mentioned, the Atlas Project out of Dartmouth has looked at local and regional variations in health services utilization. Just in one small chunk of the northeast for instance, tonsillectomies varied from fewer than 3 per 1,000 children to more than 10. Another Atlas study looked at prescription rates among Medicare patients and found wide regional variations that were not directly related to disease burden. Yet another found wide variations in the use of hip, knee and shoulder arthroplasties. And finally, one of the most disturbing is hospital readmission rates within 30 days of medical or surgical discharge. These vary quite widely and, on average, little improvement was seen between 2008 and 2010. I’m happy to say that the readmit rates here in the PNW are quite low comparatively.

    All of this by way of echoing Dr. Hall’s contrasting the approach of medicine with that of sCAMs. Medicine is extraordinarily self aware and self critical. The Atlas Project and other studies are not marketing tools for building one’s practice. They are rigorous efforts to identify and understand variations in the delivery and quality of care so as to reduce over-consumption and improve outcomes.

    Despite these diligent efforts to trim over-utilization, establish protocols and guidelines, and improve patient outcomes, medicine is still plagued with a small minority of physicians who operate as carnival barkers pushing HGH, testosterone supplementation, unnecessary surgeries and so forth. This practice is no better than garden variety sCAM as it is not based on science or evidence. It degrades medicine in the eyes of the patient population and it blurs the line between medicine and quackery. Medicine, IMHO, needs to become much more proactive in censuring and ultimately weeding out physicians whose practice deviates substantially from recognized good clinical practices.

    Those readers interested can find the Atlas Project here.

  5. Greg says:

    Let’s see – $700,000.00 median income for physician households versus $120,000.00 for the average American household. That’s almost six times as much – sounds pretty rich to me. And just because they’re on a fixed salary doesn’t mean they aren’t getting rich. Radiologists at Sick Kids Hospital in Toronto, make over $500,000.00 per year in salary.

    I do agree that doctors are often unfairly maligned and for many it is not so much about the money as caring for patients, but let’s not pretend that doctors don’t do well financially.

    1. The Midwesterner says:

      Greg – The article talks about household net worth, not income. Dr. Hall doesn’t say where she got those figures so there’s no way to know if they’re accurate or not but net worth is a long way from annual income. I don’t know what the annual average income is for American doctors but I find it very hard to imagine that it’s $120,000 for the average American non-doctor.

    2. Sawyer says:

      Greg,

      The real test is how well they do compared to people with equal talent, work ethic, and training. Practicing physicians come out ahead of some of their peers and behind others. Their salary and benefits are on par with a successful engineer, lawyer, or mid-level managemer. They come out far behind financial consultants, those working in real estate, investors, and politicians. Of course not every person working in medicine could do those jobs, but a lot of them were presented with opportunities in their life to drift into the world of finance and decided not to.

      I’d hazard a guess that most people that are accused of being a Big Pharma Shill have passed up at least one job opportunity to be, well, a Big Pharma Shill.

    3. weing says:

      “Let’s see – $700,000.00 median income for physician households versus $120,000.00 for the average American household.”
      WTF? Where did you get those numbers? I knew I was being underpaid. I didn’t know it was by that much.

    4. AstroLad says:

      “$700,000.00 median income for physician households versus $120,000.00 for the average American household.”

      Net worth, not income, big difference.

    5. The $700,000 and $120,000 figures are median net worth, not income.

    6. David Gorski says:

      Radiologists at Sick Kids Hospital in Toronto, make over $500,000.00 per year in salary.

      Citation needed.

      Also, I thought the caricature of the Canadian health system was that doctors there were underpaid relative to their colleagues in the US. I don’t know any radiologists in my part of the country who make a half a million bucks a year—or any doctors, for that matter, other than those who went into hospital and clinic management and became executives.

      1. Greg says:

        don’t have time to find new numbers – here are some from 2010 – http://surlyhamiltonian.blogspot.ca/2012/01/hospital-for-sick-children-2010.html

      2. Rob says:

        Here’s the 2010/11 average salaries for physician specialties in Canada. http://www.cma.ca/becoming-a-physician

        Radiologist is only an average of $325,000 but might be around $500,000 in expensive populated places like Toronto, Vancouver, Alberta etc.

    7. Dave says:

      Greg, Read the post. $700,000 was median net worth. Income is lower – far lower for primary care specialties. Radiologists are at the higher end of the pay scale.I agree physicians generally make a good living, but they work many hours and put in a long training time with large accumulated debt to do so. So do many other fields. They also should make a good living.

      I do think that if income were the primary driving force for physicians, many or most would be fairly satisfied. They are not. From the December 2013 issue of Mayo Clinic Proceedings:
      “The prevalence of burn out in US physicians as recently documented by Shanafelt et al is higher than in any other professionals with advanced degrees and is twice the prevalence of burn out relative to that in the general US population (46% of the physicians report at least one symptom of burn out)”

      1. Andrey Pavlov says:

        I can’t find the original article at the moment, but an amortized hourly salary was calculated for the average physician (internist) at $28/hour with the average salary across the board at $146,000. By comparison dentists make an amortized $60ish/hr and public school teachers and registered nurses right around $22-26/hour. This was calculated using the average costs of attendance to attain the requisite professional degree plus the lifetime average income averaged hourly over “standard” working hours for each speciality. For physicians, this is definitely an over estimate since they did not include any call or other random time commitments but “just” the 60-80 hours typically worked as a resident and then the 50-70 per week as an attending.

        Unfortunately there is actually a contingent of us that DO get into it for the money, prestige, and power and many of those become sorely disappointed. I actually once calculated my own personal statistics against a friend of mine. We are the same age, went to the same high school, same undergrad institution, and graduated at roughly the same time (I was 6 months behind him since I did an extra degree). Not counting compounding interest on his investments and doing a rough calculation of his assets and debts vs mine I calculated that by the time I start earning an attending’s salary I will be at LEAST $1,000,000 (yes, one MILLION dollars) behind him in terms of net worth. Granted at that point I will be making roughly 2-3 times as much as he will (all things being equal and no surprises coming our way) but he owns a house and earns compound interest while I have student loans equivalent to the value of his house which also accrue interest. Plus, in his field (computer science) he has significantly more opportunities for large boons of money, which he will most likely get. He started as employee #12 of his start up which is now in the black, producing product, and has over 100 employees. Early on they gave him $20,000 in stock options which – when they mature, unless the company goes belly up unexpectedly – will be worth close to a million dollars if not more.

        Or to put it in a different light I will have spent a total of 17 years of post-high school education and training to earn a yearly salary that will be, on average, less than 75% of what my student loans are at this moment, not counting the fact that my interest on them gets recapitalized on principal and is at an average of over 7% interest thanks to how Congress gouged me on the rates (thankfully they have – temporarily at least – ameliorated the situation, but not in time for me). My first job out of med school will pay me less than my friend’s first job out of undergrad.

        There are much, much, much better ways to make money than being a doctor. The only advantage we have is that our salary comes as a much larger chunk than most which means that IF we are smart we can use that money to wisely invest and make more money for us. But that takes expertise and time most of us don’t have. No doubt we earn a very comfortable living and should not complain about our incomes. And yes, we have a greater ability to get into “the 1%” but only IF we work hard at making our income work for us. The majority of physicians live comfortably, with little or no concern about being out in the cold or unable to afford to provide for our families, which is indeed much better off than the average American. But a far cry from being downright wealthy to the point of being millionaires and indeed I know personally of many physicians in the unfortunate circumstance of being a hospitalist in a crappy group with towering student debt, a family to support, and living nearly paycheck to paycheck.

        1. mgatton says:

          For the record, teachers contracted hours are also FAR lower than actual hours and include planning, grading student work, and consultations with parents after hours, and additional professional development required to maintain licenses (usually at teachers’ expense as well).

    8. imr90 says:

      The median household net worth is not the same as median income. Net worth is basically how much everything you have is worth. The median income for physicians is nowhere near $700,000. It’s more like around $200,000.

    9. MTDoc says:

      I believe you misread the blog. Those figures are net worth, not income. That means if you work extremely hard for 40 plus years, you can afford to retire. As for salary vs private practice, I left a very busy private practice for a job that paid 2 &1/2 times the pay and benefits with a 40 hour work week, instead of 60. And my net worth is substantially less than $700,000. Putting doctors on salaries may benefit doctors more than patients, but it will not decrease medical costs.

    10. Greg says:

      should have written – median net worth not income – sorry about that, but we’re still talking apples to apples, so to speak.

    11. Dolly says:

      Greg, the article is talking about net worth, not annual income. I do agree that a net worth six times more than average is as you say “doing well financially.”

      And I agree this is the weakest part of the author’s argument. If people cared only about money, they could go into a financial job …well, it’s sort of true. But the fact that a doctor’s income pales in comparison to some elite Wall Street person’s is a bit of an odd comparison to most Americans — because whether you perceive that doctors are “rich” and therefore might be “in it for the money” depends on whether you’re a billionaire or a bank teller.

      Doctors used to be right up there, in terms of wealth. It’s the financial speculators — and other people who manipulate money in order to make money, rather than (say) contributing anything to society — who have done very well and separated themselves from the pack, becoming our society’s ultra ultra wealthy and making the doctors look “not so wealthy” by comparison.

      But too, in the increasing pursuit of profits by the businesspeople running our health-care industry, doctors are more often earning salaries, and those salaries look less and less attractive considering their workload. More and more, doctors are treated as employees, as cogs in a profite-mailing health care machine, and not as independent professionals. Being a doctor isn’t the glam gig it once was. Many doctors these days couldn’t be in it for the money even if they wanted.

      I might take issue, though, with the straw man set up by the example of a doctor so cynical he would do an unnecessary C section because his kid needs braces. That would be pretty bad, yes. But science-based research in psychology informs us that’s not how such self-serving decisions play out for most people. It’s more like, the fact that someone needs more money is associated with him justifying more borderline cases as necessary C sections and (by the way) believing he is doing the right thing, even as the rate of Cesarean births creeps up. What people want (more money) informs their behavior (more Cesareans) but in such a way that they can maintain their self-regard (“It was a judgment call. Those patients really needed those procedures because in my judgment X indicated Y.”). It just happens to work out in our favor.

      In fact, such research in psychology would predict that most practitioners of quack-based medicine believe in themselves too. If you believe strongly in science, that idea might be hard to swallow, but a less skeptical quack might look at all those placebo effects and be the recipient of so much gratitude from people who’ve received some time and personal attention (instead of being treated like one item on a long assembly line by an overworked doctor) and therefore the quack might really believe there is something valuable in his treatments. The fact that he happens to make money is beside the point in his mind. He no doubt feels it’s just compensation for serving humankind.

      It might be hard to look at a Dr. Oz or Andrew Weil and imagine that they are not aware of what they are doing — if you believe in science, it’s easy to suppose that they are crassly and without conscience cashing in. And certainly there are a certain number of con artists in any profession — there are certainly those who are completely without conscience in science-based and quack medicine.

      But perhaps it’s important to recognize the psychology behind the majority of we well-meaning humans’ self-justifications. Part of the reason quackery is so intransigent is that most of its adherents strongly believe in it and would tell you sincerely they’re not in it for the money. That chiropractor believes that all those expensive supplements help, and that’s why he sells them so conveniently in his office.

      If we want to chip away at quackery, it’s somewhat more complicated than just exposing charlatans.

      1. windriven says:

        Well said.

      2. Self Skeptic says:

        @Dolly,
        Yes, very well said. My only caveat is, that I suspect you are underestimating how much of mainstream medicine doesn’t really work as advertised (i.e. is quackery). This includes a surprisingly large portion of the published science on which standards of care are based. I’ve taken to calling these things placeholder fictions, because the argument that I always get when exposing these fictions is “Well, it may not be ideal, but it’s the best that current science can offer,” coupled with, “Well, we have to treat based on something. We can’t just rely on clinical experience, which has been proven to be faulty.”

        I can see that these excuses represent a utilitarian solution to the doctor’s problem (i.e. believing that everything he does is helpful, or at least not harmful); but as a solution to the patient’s problem – an actual illness that doesn’t go “out of site, out of mind” after the office visit is over – it has nothing to distinguish it from quackery. Some of these standard-of-care fictions are harmful, while some are merely useless. Some are cheap in the short run (like those recommending no test, or no treatment) and some are very expensive. The important thing is that these beliefs aren’t true, and that if a doctor claims (and believes) that they are supported by science just because there are science-y looking papers in NEJM (which he hasn’t analyzed) attached to them, he’s peddling a belief system, rather than something that works, in those areas that are fictional. No amount of pointing out that the polio vaccine works, can ameliorate this problem. This is the basic error of true-believers in current “EBM” and “SBM:” Much of the E and the S aren’t convincing, upon close inspection.

        I don’t think these place-holder fictions are commonly self-correcting, from the patient’s point of view. Doctors and medical academics believe in them and are using them daily on people, so there’s little incentive to notice they’re wrong and change them. Quite the contrary – the incentive is to believe they are “science-based” and that they work.

        If it takes 20 – 50 years for each of these fictions to be corrected, that is quite long enough to hurt many patients, and it is an enormous economic burden. Patients who have suffered from these long-playing systemic errors, are unlikely to be consoled by airy assurances that the standards of care will “someday” be corrected.

        The idea that medicine is self-correcting in the same way science is, I think is too abstract to be practical, from the patient’s point of view. If a standard of care is not corrected within the patient’s lifetime, even in cases where an educated patient can see, by reading the medical literature, that it is a house of cards, then for all practical purposes that area of medicine is functioning the same way as any of the less-savory areas of CAM. (Changing one fictional standard of care to another fiction, when the first is found wanting, doesn’t count as progress. There are changes of fashion within CAM, too.) Expensive or not, highly touted, widely believed and used: but useless, or even harmful, to the patient.

        I personally am more offended by fictions in the mainstream medical literature and practice, than by those in CAM. But that’s probably because I’m a scientist and potential patient, rather than a doctor who needs these placeholder fictions in order to practice my profession comfortably. As a scientist, I don’t like having the reputation of my profession compromised by medical journals (including the most prestigious) full of exaggerated conclusions that aren’t justified by the data. It’s going to erode everyone’s trust in science, and rightly so. And as a potential patient – well, that problem is obvious.

        Again, pointing out that not all of mainstream medicine is fictional, while most of CAM is, does not address the problem. I don’t use CAM, so its fictions aren’t a problem for me and my family. But mainstream medical fictions are a big problem for us; we’ll be dealing with the consequences from those, for the rest of our lives.

        1. weing says:

          “But mainstream medical fictions are a big problem for us; we’ll be dealing with the consequences from those, for the rest of our lives.”
          And you are the unique genius qualified to determine what is fiction and what is not. I think quite a bit more self-skepticism is warranted, and not in the way you think it is.

        2. Andrey Pavlov says:

          @SS:

          Wow. What incredibly arrogant and pointless stupidity.

          I can see that these excuses represent a utilitarian solution to the doctor’s problem

          Well, let’s see. A doctor needs to practice medicine. He is forced to do so with incomplete information and, yes, incorrect information. He has no way of knowing which is incorrect or where the incomplete will ultimately lead to. He takes the best we can muster – and we here at SBM advocate to take that as far and as reliably as humanly possible – and treats his patient.

          What else would you have us do Mr. Self Skeptic? I agree with you criticism and I practice with this knowledge in mind. So just answer the very, very simple question – what should we then do? Just stop practicing medicine? At what threshold of knowledge and understanding can we go ahead and proceed to practice medicine again?

          but as a solution to the patient’s problem – an actual illness that doesn’t go “out of site, out of mind” after the office visit is over – it has nothing to distinguish it from quackery.

          What about that patient’s point of view who IS helped by medical science and the practice of medicine? WHat shall you have us do in the meantime for that person? From the patient’s perspective which would you rather have – treatment with the caveat that this is the best we know and the best we can do or the cold shoulder? Sorry SS but no medical care for you since we haven’t reached your magical threshold of scientific certainty on this treatment. If you ever get a serious disease or condition like cancer or a heart attack, I’d like to see you decline care because the level of scientific certainty is not up to your standards.

          And what distinguishes it from quackery? The very process by which it was adopted in the first place and the fact that it will be abandoned should the evidence tell us to do so. Quackery persists in the face of evidence and is completely and utterly different to mistakes made as a result of the inherent difficulties of scientific inquiry, particularly in biological systems.

          I don’t think these place-holder fictions are commonly self-correcting, from the patient’s point of view

          So of course the first part of your statement is stunningly wrong so you throw in the caveat that it doesn’t happen in a timeframe YOU like. Hey, I agree! I would LOVE to have data and evidence updated in real time to help my patients. Perhaps you would like to revolutionize the entire practice of medical and biological sciences by showing us exactly how to do that?

          If it takes 20 – 50 years for each of these fictions to be corrected, that is quite long enough to hurt many patients, and it is an enormous economic burden.

          If it takes 20-50 years? Yes, if we pull numbers out of our nether regions in order to fit the narrative we constructed we can say anything we like! It actually takes a lot less time considering that truly scientific medicine can be said to have existed for only a little over 100 years. And we nearly doubled life expectancy in that same amount of time. We’ve taken things like heart attacks, many cancers, strokes, and infectious diseases and turned them from death sentences into events that are highly survivable with good quality of life afterwards. Hell, in literally less than 20 years we took a completely unknown disease that had a nearly 100% mortality and identified it (HIV) and turned it into a chronic condition reasonably manageable with some breakthroughs in curing the disease.

          So yes, people are harmed and there are economic burdens. And yet somehow we’ve managed to do amazing things and saved vastly more lives than we’ve harmed. Oh, and we continue to improve. In fact, it was just announced that not only is quality improvement a requirement for ALL graduate medical education in the US but that our medical boards will have additional focus on QI questions.

          Not self correcting my ass.

          The idea that medicine is self-correcting in the same way science is, I think is too abstract to be practical, from the patient’s point of view.

          Ah yes, when you can’t assail the actual practice of medicine in total – that same medicine that doubled life expectancies and has literally cured many cancers – let’s go after the anecdote of the individual harmed. Focus on the numerator because the denominator destroys your argument. And then complain when that numerator is not small enough for YOUR standards. Funny thing is, we actually agree. I want that numerator to be zero as well. The difference is I don’t have an asinine understanding of the matter and think we can just magically make that happen. Once again, there is always something to criticize about literally anything. What is your proposed solution to the problem? You’ve offered absolutely NOTHING.

          But that’s probably because I’m a scientist and potential patient, rather than a doctor who needs these placeholder fictions in order to practice my profession comfortably.

          You do the profession of science a grave disservice then. You clearly do not have any actual understanding of the process, how it works and how it doesn’t. You whinge about things we all know about and then just somehow demand it magically be fixed. Yes, certain treatments and ideas do indeed rest on a house of cards. I personally advocate that unless there is a compelling reason to act, do not act. But in the meantime what shall you have us do? It has nothing to do with practicing comfortably and everything to do with practicing at all. I find it truly surprising that you are so completely blind to the implications of your statements and what they would actually translate to in real terms.

          But mainstream medical fictions are a big problem for us; we’ll be dealing with the consequences from those, for the rest of our lives.

          Agreed. Which is why we are constantly working to improve them. Once again your entire argument boils down to the process just not working fast enough for you. Well, it isn’t working fast enough for any of us. But it is the only thing we’ve got. Unless you’d care to enlighten us as to how we may speed up the process? Or better yet, fund the research yourself.

          It truly is stupendous to watch you make such incredibly banal arguments and then make them sound more interesting by shifting goalposts out so far as to make anything seem worthless. In the meantime I’ll take pride in the absolutely incredible advancements we have made.

        3. Dave says:

          Would you care to list a few of these mainstream fictions so we know more clearly what you’re talking about.

          I think what you really hate is the uncertainty in medicine. You do have a point. Guess what – we hate it too. There’s frequently some uncertainty in diagnosis, and often some uncertainty as to what the response to therapy will be. Doctors know this and have to live with it, as do their patients. You interpret this situation however to mean that doctors are unaware of it and are doing little to correct it. Since there is uncertainty, and this is undesirable, someone must be responsible. Of course, you have never read the “practice changing updates” in the resource UptoDate, have probably never perused the Medical Knowlege Self Assessment Program updates, and probably do notpersonally read the medical journals you deride. You have no personal knowlege of how different the practice of medicine is now compared to 5 or 10 years ago but pull a “20-50 year” figure out of the air. Of course your comments raise a response like Andrey’s. It would be like me seeing the news about a structural collapse of a building and then advising engineers and arcitects they should pay attention to structural forces without knowing what engineers, who know vastly more than I do about it, thought about the failures.

          It would be illustrative for you to read an article in the June 28 edition of Science entitled “The dizzying Journey to a New Cancer Arsenal”. It profiles some researchers trying to make genetically modified killer T cell therapy a cancer treatment. The first three patients with leukemia who were treated had outstanding responses, but the next three did not respond at all. The seventh, a 6 year old girl with endstage leukemia, received the therapy and nearly died from it, ending up on a ventilator for 2 weeks due to an overproduction of interleukin-6 from her revved up t cells. An arthritis drug which disables interleukin-6 saved her life, and she is now eight years old and disease free. I am sure these varying responses are not what you get in molecular biology when reactions are predictable. However, that’s the way it is when you deal with humans. The article profiles the researchers very well, with their struggles, hopes and disappointments. It would do you good to read about the people actually doing medical research. It might help with your stereotypes.

          1. Self Skeptic says:

            Part 1
            @Dave,
            I’ll just answer you; my reply will cover Andrey’s and Weing’s points, as well.

            Although I’ve appreciated your civility, and the detailed quality of your answers, in the past, I think you’re not really absorbing my posts.

            You say you think I “hate uncertainty.” As you should have noticed by now, what bothers me is not uncertainty – it is spurious certainty. That is what a placeholder fiction is. The reason it is bad, is that it stops further research from occurring, because it gives the mistaken idea that the problem has already been investigated and resolved.

            An current example would be the editorial on vitamin use in the Ann Int Med. From the title, ” Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements” one would think that the subject has been thoroughly investigated, and that a definite conclusion can be reached. But when you read the accompanying systematic review, you find that only one study has been done on the kind of daily multivitamin/mineral most people who take vitamins use – and it found that the men who took the vitamin had a slightly reduced incidence of cancer after 11 years, at p=0.04 (Study: PHS-II). (Note for beginners: p=0.04 is better than, not worse than, the usually used p=0.05. The effect meets the traditional cut-off for statistical significant, but it is a small effect.) So not only was a spurious sense of certainty created, but it misrepresented the single study that is relevant to the subject.

            Sure, the cancer finding could be a fluke, and if they repeated the study, it might go the other way. Or not. (See for example Dr. Crislip’s recent post on statistics, plus some of the comments about p values.) There are lots of reasons to want to see more studies done by different groups, as the systematic review concluded should be done, because of the popularity of such multivitamin/minerals.

            But this editorial pretends the question is settled, and even weirder, in the opposite direction from what the single relevant study shows. (The other “multivitamin” study cited, had only 5 ingredients, so it’s not typical of what most is widely used by the public.)
            (Note: Before anyone argues with me on the value of the Ann Int Med editorial, please read at least the accompanying review article in the same issue; or if it makes your eyes glaze over, at least read the last few paragraphs, about how limited the current evidence base is, and the suggestions about future research on the topic. For your convenience, here’s a link to the editorial,
            http://annals.org/article.aspx?articleid=1789253&resultClick=3
            and to the review:
            http://annals.org/article.aspx?articleid=1767855

            This is long enough for Part 1.

            1. weing says:

              “As you should have noticed by now, what bothers me is not uncertainty – it is spurious certainty.”

              What is spurious certainty? Anything other than death and taxes, I suppose. I think you must have read a different article if you think it claims to resolve all questions.

              1. Self Skeptic says:

                @Weing,
                I presume you’re talking about the editorial.
                Look at the title, and the last paragraph. If you think these authors are adequately communicating to the their readers the skimpiness of the data, and the consequent prematurity of any opinion at all on the matter, then yes, we must be reading two different articles.

              2. weing says:

                I guess you’re right. I ignored the editorial. Everyone is entitled to their opinion. That doesn’t mean I need to agree with them 100%.

              3. MadisonMD says:

                @Selfie

                An current example would be the editorial on vitamin use in the Ann Int Med. From the title, ” Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements” one would think that the subject has been thoroughly investigated, and that a definite conclusion can be reached.

                I don’t really have a problem with the editorial. The title and last paragraph adequately state the case:

                Although available evidence does not rule out small benefits or harms or large benefits or harms in a small subgroup of the population, we believe that the case is closed— supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful. These vitamins should not be used for chronic disease prevention. Enough is enough.

                Sure science can’t rule anything out 100%, but we can say:
                (a) The current state of evidence does not support vitamin use for prevention of chronic disease in well-nourished adults.
                (b) Research on the most promising hypotheses over decades have basically turned up no benefits– therefore we should invest very limited research resources in other avenues of inquiry.
                I would sum up the above as enough is enough.

                We can argue about multivitamin use and cancer prevention if you wish but a weakly positive study doesn’t trump multiple negative studies, especially when there is no obvious mechanism.

              4. Self Skeptic says:

                @Maddie,

                There has only been one study, of a many-ingredient multivit/min, according to the systematic review. Since this is what most people who take a daily vitamin use, that is the only relevant study. However many negative studies there may be of, say, vitamin C, or E, or whatever, they are irrelevant to the utility of the “popular multivitamin/mineral” question. (The existence of hyped claims for various vitamins and minerals, are also irrelevant to this question, in case that’s your issue.)

                I’m not seeing any reason to regard the hypothesis, that we (scientists and doctors) can’t be sure people are getting all the nutrients they need from the SAD, as wildly implausible. Seems unobjectionable to me, and I’m a mammalian biologist.

                Without more data, we can’t know one way, or the other.
                I don’t have any affiliation with a group that is either pro- or anti- vitamin. Perhaps you are (socially and intellectually, not financially) affiliated with a group that has a pre-existing attitude on the subject? Otherwise I don’t see where your opinion is coming from.

                In the absense of sufficient data, there should ideally be no strong opinions. (I don’t have one, myself, on the subject.) if there are, and they must be aired, two editorials laying out the reasoning of each “side” should be published. (Emphasis: this is in the absense of sufficient data.) Or the unsubstantiated but strongly felt opinion should be expressed on someone’s blog, not published prominently in the Ann Int Med, where it can be expected to fool many gullible physicians into believing it is science-based.

                (Obviously, you disagree; that’s fine. I just want to make sure people understand the standard scientific approach to such matters, and it falls to me to explain it, as scientists are under-represented here.)

              5. MadisonMD says:

                There has only been one study, of a many-ingredient multivit/min, according to the systematic review.

                This is a bit misleading. There are many observational studies which fail to support the hypothesis. Moreover, randomized studies of the most promising single vitamins have failed to pan out. There are no specific mechanisms and multiple hypotheses are tested in PHS II. You seem to be making the clasic EBM error of ignoring all evidence that doesn’t come from a randomized trial… and then, moreover, saying a single 10-year randomized trial isn’t enough.

                I’m not seeing any reason to regard the hypothesis, that we (scientists and doctors) can’t be sure people are getting all the nutrients they need from the SAD, as wildly implausible. Seems unobjectionable to me, and I’m a mammalian biologist.

                Absolutely–we can’t be 100% sure… but we are fairly damn close. Give me a shred of evidence, please. Where are the people who are ill with vitamin deficiencies? As a mammalian biologist, where is the preclinical evidence that higher-than-necessary vitamins would prevent chronic disease? We’ve studied vitamins for decades; there are so many more promising scientific vistas to explore.

                Perhaps you are (socially and intellectually, not financially) affiliated with a group that has a pre-existing attitude on the subject? Otherwise I don’t see where your opinion is coming from.

                WTF? Why do you think that someone can have an opinion that is not based on bias from an interested group? Is your opinion based on such a bias?
                In answering your question directly, I would have to say that my affiliations are with science and medicine.I don’t really give a damn whether vitamins prevent chronic disease or not– actually I’d prefer it if they did. My thoughts are that after large and expensive studies, lack of observational data for multivitamins, and lack of plausible mechanism and preclinical data, limited research resources should be invested in more plausible science.

                In the absense of sufficient data, there should ideally be no strong opinions.

                So you should have no strong opinion about, say, homeopathy preventing chronic disease? Science isn’t about proving the negative, it’s about selecting and investing in the most promising hypotheses with potential to help people. I would change my mind if you, a mammalian biologist, go back to the lab and develop preclinical evidence and delineate a plausible mechanism to develop a specific hypothesis about how a specific vitamin prevents chronic disease. Then I would want to see obervational data. If these preliminary data look promising, then I would change my mind. I would want to support a placebo-controlled study to test this specific hypothesis. Without it, I’d like to invest in clinical research based on strong preclinical data.

                Obviously, you disagree; that’s fine. I just want to make sure people understand the standard scientific approach to such matters

                You are correct. I do disagree.

                and it falls to me to explain it, as scientists are under-represented here

                WTF? So your opinions are the only informed ones? For the record I am scientist as well as a physician. By your logic, does that make my opinions more valuable than yours?

                Good day.

              6. Self Skeptic says:

                @MadisonMD,

                Fine, we’ll agree to disagree about whether there is sufficient evidence about multivit/min use, to justify an opinion.

                Please compile citations, of these observational studies of multivitamin/mineral use you mentioned, and I’ll see if they change my mind.

                I’m curious; what kind of scientist are you? Did you train primarily with MDs, or PhD’s? (Not that a PhD is necessary, or any guarantee, for understanding the minimal necessary criteria for “true” science.) But I’d like to know if you have any scientific experience outside the culture of medicine, so as to understand if our differing educations might account for our disagreement on where burdens of proof should fall, what is plausible and what is not, etc. Alternatively, it could just be a difference in temperament, a generation gap, family background, or who knows what.

                I don’t really understand your claim of lack of mechanism, for the (mostly) RDA-dose multi like Centrum. The proposed mechanism is that of trying to optimize nutritional status, based on what’s known about required micronutrients. We don’t eat monkey chow, so we don’t really know what we’re getting in our food; hence the multivitamin/mineral pill. That rationale fulfills the function of the “mechanism” caveat, well enough, for me.
                I did read this editorial, which you probably also read.
                http://jama.jamanetwork.com/article.aspx?articleID=1391897
                I’m not protesting this one, because it’s not dictatorial in tone, like the Ann Rev Int one. But I don’t find it especially compelling. I’ve worked on enough projects that were thought implausible, but that worked, to view plausibility as a highly subjective thing, within obvious physical limits.

                Regarding the absence of deficiency diseases, I don’t think we know that, either. Maybe there are, maybe there aren’t. There are scores of conditions considered idiopathic, plus tens, maybe hundreds of thousands of patients with what I’ll call mystery illnesses (like ME/CSF, fibromyalgia, and other diagnoses of exclusion). Though some doctors do take the radical position that any disease for which a physical cause cannot currently be assigned with confidence, must be psychosomatic, I doubt you’re that naive about the completeness of our current state of knowledge.

                Homeopathy has nothing to do with this, for obvious reasons. But I think your mentioning it, alongside your thinking that large-dose single vitamin studies for some specific condition are relevant here, might provide me with a clue. Could it be that you have somehow conflated RDA-dose pills used as a nutritional strategy, with disproven or unproven claims that mega-doses of some vitamin or mineral will cure some particular illness or act as a panacea, like Pauling’s vitamin C claims? These two uses of vitamins are as different as day and night, and I don’t see how a case can reasonably be made, that negative trials on the latter, are relevant to the former. Regarding the low-dose multi as a gateway drug for CAM, also doesn’t seem plausible, to me.

                Please do let me know generally what your training is, and what kind of research you do. Mine is what you’d expect; grad school with a mature PhD mentor; though I did my postdoc with an MD/PhD.

              7. Sawyer says:

                @ SS.

                The idea that moderate claims for supplement benefits should be evaluated separate from Pauling’s work is a reasonable, but let’s not pretend that every hypothesis being tested deserves to be treated as completely independent. Vitamin research is viewed with extreme scrutiny because the authors of many studies attach an unreasonably high prior plausibility to their hypotheses. It is NOT unfair to point out the origin of these misconceptions. If you follow the history of this research closely you realize the tremendous amount of papers that should have already been published proclaiming moderate benefits when Pauling’s work was in its heyday.

                Science does not happen in a vacuum. I think it’s naive to pretend that supplement research in 2014 isn’t still somewhat influenced by the shoddy work in the 60s.

              8. Self Skeptic says:

                @Sawyer,

                Thanks for discussing.

                Yes, I think everything in science should be rigorously scrutinized. That’s required, to execute the self-correcting function. No one individual can critique every paper that is published, but together we can (or theoretically could) keep it reasonably clean, with diligence. If shoddy papers about vitamins were published in the past, and fooled people, that means that the peer reviewers and people working at the journals need to sharpen up their critical skills, and make sure people aren’t making claims that the data don’t support. But scientists should be doing that routinely. If not, something is wrong.

                If much flawed research was published on vitamins in the past, that does not supports the Ann Int Med editorialists, or MadisonMD’s, strong claim that no valid research on vitamins should be done, or could be done. By making that unwarranted leap, in my view they is making the same mistake the flawed vitamin study authors made. Which is, making strong claims that are not supported by good evidence.

                This repeats and compounds the problem, rather than fixing it.

                There’s no rational connection there. It all seems to be based on an acquired, emotional distaste, triggered at the mere mention of a buzz word: vitamins. This can be explained; it’s a kind of Pavlovian reflex, I guess. But it can’t be justified; it’s not a rational or scientific approach to the topic.

              9. MadisonMD says:

                @SS:

                Please do let me know generally what your training is, and what kind of research you do. Mine is what you’d expect; grad school with a mature PhD mentor; though I did my postdoc with an MD/PhD.

                I don’t think credentials are really relevant to the discussion. If you must know, my PhD is in chemistry and postdoctoral/fellowship training in molecular/cell biology. I train MD/PhDs.

                Please compile citations, of these observational studies of multivitamin/mineral use you mentioned, and I’ll see if they change my mind.

                Observational data on multivitamins (MVIs) for cancer are referenced in PHSII:

                WHI study: N=161,808, followup 16 years, no effect of MVI on cancer.

                Swedish breast cancer study: More breast cancer with MVI.

                Skin cancer study: borderline protective effect.

                Breast Cancer mortality meta-analysis: N=355,080; No effect on breast cancer mortality.

                Mortality study: No effect on all cancer mortality; N=77,719, 10-year followup.

                Prostate Cancer case-control study: Prostate cancer cases more commonly associated with multivitamins use. (but only if they contained zinc; no difference without zinc).

                Multivitamin in Colorectal cancer study: showed no association of MVI with mortality. Folate-containing subset was marginally positive.

                Another Multivitamin in Colorectal Cancer NHS: N=88,756, did show a significant reduction in CRC, only at one timepoint (>15 years) but not at other times. Authors speculate that it is from folate (but subsequent randomized trials of folate negative, summaried in meta-analysis here)

                So enough is enoughfor cancer. I don’t really have the time or patience to look at all the observational for each chronic disease.

                I don’t really understand your claim of lack of mechanism, for the (mostly) RDA-dose multi like Centrum. The proposed mechanism is that of trying to optimize nutritional status, based on what’s known about required micronutrients. We don’t eat monkey chow, so we don’t really know what we’re getting in our food; hence the multivitamin/mineral pill.

                This is an extremely superficial “mechanism,” devoid of specificity for a particular disease or a particular vitamin. Here are some questions that will help you get at specificity:
                * How do you define “optimizing nutritional status” ?
                * What has this to do with cancer or other chronic diseases?
                * More specifically, for cancer, which nutrient is having a biologic effect on cell proliferation, immortality, DNA damage, angiogenesis, loss of contact inhibition, migration?
                * In what model systems or human case series has the lack of the nutrient been demonstrated to cause cancer?
                * Does repleting the requisite nutrient(s) prevent or control cancer in a model system?
                * Why does the mechanism require a combination of 30 micronutrients… or would fewer suffice?

                Answer these questions and then you have a specific mechanism. These questions would need to be answered–with data–and found to be consistent with the failure of the existing studies to find an effect. Only then would I support investing time, money, effort, and resources into a clinical study testing the hypothesis … And, then I would support a study that is designed to evaluate only the specific nutrient(s) for a specific disease. It would include correlative analyses of blood or tissue to probe the specific mechanism.

                If much flawed research was published on vitamins in the past, that does not supports the Ann Int Med editorialists, or MadisonMD’s, strong claim that no valid research on vitamins should be done, or could be done.

                You misapprehend me. My opinion is that the valid research should be done in the lab not in the clinic, up until there is a specific mechanism as I describe above, coupled with observational data. Then, and only then, would I support investing resources of the specific nutrient(s) which are thought to prevent chronic disease. Without it, just grinding out more clinical investigations of multivitamins is akin to hunting snipes with grapeshot.

                Why are you against investing the resources, instead, in research questions that have not been tested yet? I find investigation of new things so much more interesting… and more fruitful.

              10. MadisonMD says:

                Ooops. One observational study link was broken. Here it is:

                Swedish breast cancer study: demonstrating a higher incidence of breast cancer in women taking MVI than those that were not. N=35,329

              11. Self Skeptic says:

                @MadisonMD,

                Thanks very much. I’m reading through the papers you kindly cited. I skimmed the Women’s Health Initiative study, and it looks impressive; I’ll continue and get back to you.

                I agree that credentials aren’t the most important thing, and can even be misleading. But I wanted to know if we were likely to have any, well, common language, and thought that training history might be a clue. I’m aware (at least somewhat :) ) of how my field biases my perceptions and preferences, and have no reason to think that anyone else is free of such influences. I feel that bias is inevitable, but self-knowledge and attempts to correct for it, are a kind of voluntary project, that not everyone undertakes. Feynman’s precept of “bending over backward to show how you might be wrong” is a good guide.

                You have an MD too, right? (from your ‘nym). Have you noticed systematic differences between the scientific culture, and the medical one? It was quite striking to me, when I first started reading the medical literature. Granted, I started out with a controversial topic, and controversy can be (though isn’t necessarily) a sign that something is unusually wrong with the majority view. I admit I’m not very interested in investigating the things that are going right, though somebody needs to do it; I’m a trouble-shooter, by temperament. But even after trying to correct for that bias, it seems to me that the social needs of physicians (and of patients) to feel confident in the face of a threat to health, plus the inability to do studies with all the variables controlled, makes clinical science prone to premature closure, and susceptible to reifying the placeholder fictions that have been introduced. No doubt, basic science succumbs to this too; but the felt urgency to do so, seems likely to me to be much greater in medicine, where each patient needs advice and care, now. I’m not at all knocking doctors, or patients, for this; if I were in their shoes, I’d probably do the same. It may be that it’s not optional, but a necessary part of the job. But I think it does slow down the progress of medical science, when people take this understandable desire for certainty, and turn it into a belief that we have it, even when we don’t. It also leads to sometimes-vicious political battles, when people get highly invested in defending cultural agreements (placeholder fictions), as if they were scientific facts.

                Okay, off to get up to speed on these observational studies. Thanks again, for compiling them. And for not lecturing me, on not having culled them myself, from the review. :)

              12. MadisonMD says:

                @SS:
                I appreciate your thoughtful reply. Admittedly I have biases, too. But my opinion is (I hope) based on how I think hypotheses should be developed and applied to medicine rather than an unwarranted bias against vitamins.

                Yes, I also am a trained MD physician and yes, I do think there is a yawning gap between culture of basic science and medical practice. I have seen it. I, too, wish this gap could be closed– in fact closure of this gap is, I think, the answer to addressing the many potential hypotheses about vitamins and chronic disease.

                Integrating basic and clinical observation

                … inability to do studies with all the variables controlled, makes clinical science prone to premature closure, and susceptible to reifying the placeholder fictions that have been introduced.

                This is exactly why we need science-based medicine–the synthesis of basic and clinical science. This is, in fact, what attracts me to this blog. The writers on SBM have clearly laid out the case for integrating knowledge from both basic and clinical research to evaluate and sort among the most promising hypotheses. You are correct to point out that clinical studies lead us to falsely reject a true hypothesis or accept a false one. (I agree with you that MD’s may overvalue the results of a RCT in either direction as well). This is the very reason for SBM– it looks for concordance of many lines of evidence and evaluates RCT results in the light of prior plausibility.

                Clinical experiments can take a dozen years to complete and yet have only alpha=0.05 and power of 0.8. My point is that RCT is the wrong tool to use when there are many potential hypotheses to be explored. The exploration should be done prior to the RCT both in the laboratory and observational evidence from existing data– this generates strong plausibility prior to starting the RCT.

                If you use basic/lab research first, and then clinical evalution, science becomes more powerful and efficient to sort through the infinite haystack of potential hypotheses to discover–and validate– the needles of truth. The RCT should be reserved for the validate part. [NB. I am not, I hope, undervaluing clinical observation-- this could also help generate the hypothesis; I'm just saying that the clinical observations for multivitamins do not support the plausibility of hypotheses about MVI preventing chronic disease.]

                Practice of SBMThe practice of medicine, which you also allude to, is distinct from clinical research. Practice necessarily involves additional uncertainties. The “practice of SBM” if you will involves judgement in applying scientific knowledge to make recommendations that, may not strictly fall within the boundaries of clinical investigation, but based on the totality of what is known is likely to improve or maintain the health or alleviate suffereng of your patient.

              13. Andrey Pavlov says:

                @MadisonMD:

                I can’t reply under the thread, but agree wholeheartedly with your most recent comment to SS about the gap between basic and clinical sciences, the overvaluation of RCTs, and the purpose of SBM. This all falls well within Dr. Hall’s idea of “Tooth Fairy Science” and what Dr. Gorski has called “methodolatry” in regards to the overvaluation of RCTs.

                Converging lines of evidence, not defined by but heavily informed by, the basic sciences is the key to SBM and what I (and I reckon we) think is the best practice of medical science and medicine.

          2. Self Skeptic says:

            Part 2
            @Dave,

            Dave said: “Of course, you have never read the “practice changing updates” in the resource UptoDate, have probably never perused the Medical Knowlege Self Assessment Program updates, and probably do notpersonally read the medical journals you deride.”

            You’re mixing apples and oranges here, in addition to making unsupported assumptions about me. The sites you use to keep up to date, aren’t relevant to the issue I’m addressing, though I have looked them over. I’m concerned that quite a bit of the information on those sites, no matter how recently updated, was generated by ignoring conflicting data, in favor of rendering decision-making fast and simple. That’s how guideline-making seems to work, even in the full articles presenting the guidelines (usually in specialty-society journals). Ditto for “care pathways,” discussed in the book by Harvard physicians’ Wen and Kosowsky, “When Doctors Don’t Listen”. The summary sites you reference are often even less informative.

            Here’s an excerpt from a discussion of UpToDate (UTD) which includes the criticism I feel to be most relevant here:
            http://laikaspoetnik.wordpress.com/2009/04/05/how-evidence-based-is-uptodate-really/
            I suggest you follow the link and read the whole discussion.

            snip
            Although it is an impressive list of EBM-sources, this does not mean that UpToDate itself is evidence based. A selection of journals to be ‘handsearched’ will undoubtedly lead to positive publication bias (most positive results will reach the major journals). The electronic searches -if done- are not displayed and therefore the quality of any search performed cannot be checked. It is also unclear on which basis articles are in- or excluded. And although UpToDate may summarize evidence from Systematic Reviews, including Cochrane Systematic Reviews it does not perform Systematic Reviews itself. At the most it gives a synthesis of the evidence, which is (still) gathered in a rather nontransparent way. Thus the definition of @kevinmd comes closest: “it gives an evidence based slant”. After all, Evidence-based medicine is a set of procedures, pre-appraised resources and information tools to assist practitioners to apply evidence from research in the care of individual patients” (McKibbon, K.A., see defintions at the scharr webpage). Merely summarizing and /or referring to evidence is not enough to be evidence based.
            It is also not clear what peer reviewed implies, i.e.can articles (chapters) be rejected by peer reviewers?

            As a consequence the chapters differ in quality. Regularly I don’t find the available evidence in UpToDate. That is also true for students and docs preparing a Critically Appraised Topic (CAT). In my experience, UpToDate is hardly ever useful for finding recent evidence on a not too common question. @Allergynotes tweeted a specific example on chronic urticaria and H. pylori, where the available evidence could not be found in UpToDate.
            In an older post (2007)*** @Allergynotes (Ves Dimov) commented on an interesting post by Dr. RW: “Are you UpToDate dependent?” by citing an old proverb: “beware the man of a single book (homo unius libri), which describes people with limited knowledge. The current version of the Internet has billions of scientific journal pages and the answer to your questions must be somewhere out there.” Ves:

            “I don’t think anybody should be dependent on a single source. If one cannot practice medicine without UpToDate, may be one should not practice at all.”

            Likewise, an anonymous commenter on Kevin’ posts stated:

            “Don’t overlook the fact that there is a lot of good research outside of UpToDate. This is a great source, but if it’s your only source you’re closing off a tremendous amount of the literature. The articles are also written by people, and are subject to the biases of individuals.”

            In another comment Dr. Matthew Mintz of the excellent blog with the same name puts forward that many of the authors have substantial ties to the pharmaceutical industry, meaning that UptoDate (although not financed) is not completely unbiased.

            snip

            I get it, that MDs, especially those in a general practice, need this kind of simplification, and that there’s no other way for you to practice. I don’t fault you for doing it that way, at all. I’m not personally challenging any of you for the way you’re practicing; I think you have no choice, and I bet you’re all conscientious clinicians, devoted to providing the current standard of care to all your patients. Furthermore, if you’re young, you simply don’t have enough experience to notice yet, if any of it is obviously not working as claimed. I only fault you, for assuming that I also lack the relevant training and experience, to evaluate some of the flimsier constructs being used as current standards of care.

            But your immediate practice needs, shouldn’t keep you from considering these issues, especially on a site that claims to be about science-based medicine. Wrong standards of diagnosis and care can exist for many reasons. Tops on my list of reasons, are because of poor-quality science being mistakenly accepted and built upon; and because of skewed perceptions of the existing science due, I presume, to intellectual bias, like that we saw in the Ann Int Med editorial above. Frequenting a site like SBM that routinely mocks dissenters from current standards of care, without regard to the quality or substance of the dissenters’ critiques, encourages physicians to think in a way that acts against the self-correction of systemic medical errors, not in a way that helps to correct them.

            End of Part 2

            1. weing says:

              “Frequenting a site like SBM that routinely mocks dissenters from current standards of care, without regard to the quality or substance of the dissenters’ critiques, encourages physicians to think in a way that acts against the self-correction of systemic medical errors, not in a way that helps to correct them.”

              OK. So you are the arbiter of the quality of the dissenters’ critiques? Your beef appears to be that, since medicine is not perfect and studies are not perfect, then we should not base our practice on the tentative knowledge base we have but something else. That we should take seriously those advocating deviation from standards because you have decided that their quality is not wanting and we have somehow missed that. Laughing at and mocking what we see as stupid is counterproductive to science and self-correction, as you assume we are mocking the dissenters and not their recommendations. Do I read you correctly?

            2. Andrey Pavlov says:

              @Self Skeptic:

              if I were in their shoes, I’d probably do the same. It may be that it’s not optional, but a necessary part of the job.

              The most correct thing you’ve said and exactly the point we here have been trying to make. We acknowledge the flaws and drawbacks and are always striving to do it better. But things don’t just magically happen.

              But I think it does slow down the progress of medical science, when people take this understandable desire for certainty, and turn it into a belief that we have it, even when we don’t.

              The question is “slower than what?” Everything slows down the process of all sciences. But it is a meaningless statement unless you compare it to a different way of doing it and saying “it is slower than that way.” Lack of funding also slows down progress. At least we have a somewhat straightforward way of fixing that. But imagine if all funding available is spent – literally impossible to squeeze out more (for hypothetical purposes of the thought experiment). You could still say “the lack of more funding is slowing down progress.”

              And that has been at least my main criticism of your arguments. That you just say [x] is slowing things down. Gotcha. Do you have a better way? A better idea? We work within the confines of reality.

              As for turning it into a belief – your “placeholder fiction” idea – I think you are fundamentally wrong in this. We simply cannot operate in a state of constant doubt. And while some physicians accept wholesale a “placeholder fiction” to the point where it precludes changing one’s mind or ideas, the vast majority don’t. And our education and training is specifically such to disengender that sort of thinking. And SBM is all about making that abundantly clear. However, there are things that we can be pretty darned confident about. And while Feynman was right in saying that we need to be able to hold ideas in limbo and be content with admitting “I don’t know” it would also be perverse to act as if certain things cannot be confidently said despite the fact that there is a non-zero chance we may be wrong. Not only from a legitimately scientific standpoint but even moreso in medicine from a humanistic standpoint. Would you like to go to a doctor who says, “I dunno. Could be [a,b,c,d, or e] so we can’t really help you.” Of course not. Certainty is a relative thing. You, in your field, will never achieve the certainty of a particle physicist. So they can lambaste you about your placeholder fictions. What matters is how much certainty we can reasonably have and act upon. That is necessarily less certain in medicine than in lab based mammology than in particle physics.

              The offensive error that you make is thinking that we, as a whole, just completely buy into these “placeholder fictions” as if they were the gospel and we were the uncritical believers.

          3. Self Skeptic says:

            Part 3

            Dave, your remark about my probably not reading articles in the journals I mention, is way off the mark. Certainly I’ve never read a whole issue of Ann Int Med; I choose a topic of interest, and read an assortment of articles on that topic, including those needed to get me up to speed, on the background of the field, from a wide variety of mainstream journals. If there’s a controversy, I read a variety of the best arguments on both sides, and mull over their relative merits.

            Since this “probably” is not about me, maybe it’s about you. Do you read journal articles? I read a lot of reputable books about medicine, too, including its history. I’d be glad to compile a list of my favorites, if anyone is interested.

            Weing and Andrey’s doubts notwithstanding, I wouldn’t presume to have opinions about these issues, if I hadn’t researched them extensively. I got serious about it in 2007, and I didn’t post a word about it anywhere, until 2011, when I felt I had a good-enough knowledge base to say something worthwhile. I still do a lot more reading than writing on the subject. And as you can see from my presence here, I’m conscientiously exposing myself to opinions that don’t agree with mine. This is in addition to my 30+ years in science, including two successful drug development efforts. Although you may disagree with my conclusions, your assumption that I’m inexperienced, or failing to exercising due diligence before posting, seems more like an attempt to discredit the messenger, than a realistic response to my posts.

            1. Dave says:

              No doubt you are well read. You make some valid points.

              The thing I think is wrong about your posts, (and I could be mistaken on this but I doubt it from your posts), is that you seem to think physicians pretty much swallow whatever we are fed without critical thought or skepticism on our own and are unaware of problems in medicine such as the possibility of working on a wrong diagnosis, which has actually been pretty heavily written about. I don’t mind it if someone points out some of the defects of modern medicine, of which there are many. I do mind it when they accuse the practitioners of being shills or pawns for big pharma, only in it for greed, etc. The first post of yours I read you commented about a young doctor who undoubtedly thought all academic physicians were saints, or something to that effect. This might have been an attempt to be humorous but I thought it was insulting.
              You’ve also made statements to the effect that it takes 20-50 years for practices to change (note I referenced the “Practice Changing Updates on UptoDate as an example of recent changes in practice). I have no idea where you got that figure. Any physician who has been in practice any length of time is exposed to changes in practice, often dramatic reversals. To name a very few I’ve witnessed, when I was in medical school beta blockers were contraindicated in heart failure. Now it’s pretty much malpractice not to use them for compensated heart failure. Hydralazine was contraindicated in heart patients. Now it is used with nitrates for patients with heart failure who cannot tolerate ace inhibitors. We were using warfarin routinely for strokes. Now we use it only for strokes due to cardiac emboli, generally from arrhythmias.Postmenopausal estrogens were supposed to be protective against heart disease. We found they do the opposite. It’s been stated many times in this blog that medical students are routinely told that much of what they are taught will be changed in the future. It’s pretty hard to be a physician and not be somewhat skeptical about the current recommendations or guidelines when you know they’ll be different in a few years. This may be one of the reasons why new things take a little time to get universally adopted, which doctors have been criticized for. There’s a saying in medicne, “you don’t want to be the last person to use a new therapy but it’s also not wise to be the first”.

              I’ve been doing this for 36 years. When I finished training there were hardly any nsaids (only motrin), no dmards, no ace inhibitors, no ARB’s, no lovenox, no platelet inhibitors other than aspirin, no biological agents for inflammatory bowel disease, arthritic conditions or cancer, no cardioselective beta blockers, no second or third generation cephalosporins, no flouroquinolones, hardly any antiviral agents, no linezolid or teicoplanin, no serotonin reuptake inhibitors, and only phenobarb, tegretol and dilantin for seizures. The antiarrhythmic agents we had are now almost never used. The only thing we had for MS was steroids. As far as new diseases I’ve seen the discovery of AIDS, Lyme disease, Legionaire’s disease, hantavirus, hepatitis C and D, c diff, h. pylori and SARS just to name some of the infectious diseases.

              It takes 20-50 years for practice to change?

              I think if you read any of my posts you’ll see I read journals. In my last four posts I’ve quoted three, one an article from the NEJM two weeks ago and one from The American Family Physician in Sept 2013. The last post here I mentioned an article in Science.

              1. Andrey Pavlov says:

                is that you seem to think physicians pretty much swallow whatever we are fed without critical thought or skepticism on our own and are unaware of problems in medicine such as the possibility of working on a wrong diagnosis

                Indeed this does actually happen, but it is the minority and the exception. That is not how we are taught or trained and it is something actively combatted literally daily. That is actually part of the reason I love working in the ICU so much – we have a relative paucity of data on many aspects of care and there is simply no way our patients in the ICU actually “fit” any particular study perfectly – they are too complex and comorbid. So we piece things together and argue and go all the way down to basic sciences (and to be clear “basic” means “fundamental” not “simple”) when we must in order to guide our actions and inactions. As one of my ID attendings used to say – the hardest thing to do is practice MICO: Masterful Inactivity and Catlike Observation. We have daily, yes daily conferences to discuss cases and evidence for management and how we can improve it, where the evidence fails us or our patients, and how to work within the confines of reality. Those confines being that we must try our best to save or ameliorate a life when we don’t have the clearcut knowledge of exactly how to do that.

                There’s a saying in medicne, “you don’t want to be the last person to use a new therapy but it’s also not wise to be the first”.

                True. A fine line to walk indeed. Xigris comes immediately to my mind.

            2. Andrey Pavlov says:

              Although you may disagree with my conclusions, your assumption that I’m inexperienced, or failing to exercising due diligence before posting, seems more like an attempt to discredit the messenger, than a realistic response to my posts.

              Well that was a very Chopra-esque defense. When Dawkins and Harris said Chopra was fatuous and had no idea what he was talking about he angrily stated how many chaired professorships he held, how many articles he’s published (laughably he specifically mentioned an article in Cosmology which is a hack journal and everyone except he knows that), and who he collaborates with as if that somehow demonstrated that we should respect his conclusions.

              I have no doubt that you have read and studied and worked as much as you say. But that doesn’t mean you’ve actually understood what you’ve learned. So the fact that we say what we do is a reflection of what you are actually writing. And in fact it makes it a little sad that after all that effort you still write and proffer ideas as if you were rather unstudied on the topic. Obviously you don’t see it yourself – which is perfectly understandable, we all view our own writings and thoughts through our inescapable cognitive biases. The issue is that you seem to be utterly convinced that your understanding of the matter is unimpeachable despite that fact that other scientists are telling you otherwise. And not just other scientists but actually medical scientists who are themselves physicians as well. I fall into that category, though I am very early in my career. MadisonMD and Dr. Gorski also fall under that category and have vastly more knowledge and experience than I. Yet we all agree. There’s that old saying that when you think everyone else in the room is crazy, perhaps it is you who are crazy. A little introspection on your part is in order.

            3. Andrey Pavlov says:

              For some reason the threading is just not working with my browser and I cannot “reply” to the actual post you made so I’ll just have to do it here and reference your post. MadisonMD already handily demonstrated your folly, but I thought there may be a couple of points to add.

              There has only been one study, of a many-ingredient multivit/min, according to the systematic review. Since this is what most people who take a daily vitamin use, that is the only relevant study.

              This, right here, is precisely why we are saying you do not have an appreciation of how medical science actually works. You are trying to shoehorn in the practice of medical science into your paradigm of mammalian biology. The problem is that we cannot ethically conduct science on humans in the same manner. We also cannot simply live in limbo, paralyzed and incapable of drawing a conclusion, until such time as every nuanced question is answered in a manner and certainty consistent with other fields of science.

              In this case, we have multiple lines of evidence all converging on the same conclusion – routine supplementation of vitamins does not have any indication of benefit. We do not need a massive study of “real world usage” of multivitamins to draw this conclusion. And in fact, your implicit assertion is profoundly unscientific by any standard. Your position would require that whilst individual vitamins don’t have demonstrable health benefits and a large and extensive trial of multivitamins was concordant with this, along with the basic sciences giving us no plausible mechanism that somehow a trial of your “real world usage” of multivitamins will demonstrate something different. Is this possible? Yes, of course. Is it likely? Absolutely not. Literally everything from basic sciences to large RCTs shows us either negative results (mostly) or equivocal results. So wherein lies the prior probability that this one particular mix of vitamins will behave differently?

              Furthermore, the data we do have gives as a rough delimitation of what effect size we could expect to see – which MadisonMD stated. Either the effect is there but so small that it really isn’t worth pursuing or the effect is profound but only in a very small subset of the population. If the former, I say it is not at all worth our limited time, money, and resources to try and find out. If the latter, I think it would behoove us to find out and hopefully someday we will but currently the return on investment is vastly, vastly too small to be worthwhile.

              Which means, from a medical science perspective, it is perfectly reasonable to conclude that “enough is enough” and advise against routine vitamin usage. Not enough to really try and actively dissuade use in the way we would our patients who are drug addicts, but enough to advise our patients not to waste their money on multivitamins and prescribe them only in indicated populations (and yes, there are actually populations easily identifiable for whom it is reasonable to recommend vitamin supplementation).

              However many negative studies there may be of, say, vitamin C, or E, or whatever, they are irrelevant to the utility of the “popular multivitamin/mineral” question

              And this, right here, is precisely where you are wrong. Unequivocally and absolutely dead wrong. All those negative studies are indeed very relevant to the question because they offer converging lines of evidence to demonstrate a lack of effect from routine vitamin supplementation. Once again, unless you are wishing to posit some extraordinarily unlikely synergy in multivitamins for which there is no evidence (the one large and long RCT) or some kind of magical effect.

              You are falling into the trap of the CAM minded. Echinacea is a prime example. How many studies were done – all of them negative – before finally concluding it really doesn’t work? And yet still we find papers being written where the introduction says something to the effect of:

              Previous studies of Echinacea have been negative but we are testing [this specific subtype of species] with a higher concentration of [some random biomolecule found in Echinacea] and using only the [insert part of plant here] to see if that has an effect…..

              Does that sound reasonable and scientific to you? Because that is precisely what your arguments here have amounted to. Well all this other data is negative and the one large trial is also negative, but maybe this particular formulation will work. And maybe we can find a unicorn somewhere if we just look hard enough.

              Yes, of course, to directly answer the specific question we would need to do studies on that specific scenario. But there are limitless “specific scenarios” one can contrive to spin our wheels and publish garbage. The whole premise of SBM is to say that once the evidence – from lowest tier to top – converges on a negative or equivocal result with the remaining uncertainty leaving room only for clinically insignificant effects we declare the issue dead and move on.

              You do understand the difference between statistically significant and clinically significant, right?

              In the absense of sufficient data, there should ideally be no strong opinions.

              Sure. Nobody here would argue with that premise. But what you consider “sufficient data” is not what we consider sufficient data. And we are, in fact, not only scientists but scientists in the relevant field and actual clinicians to boot. So when you say:

              I just want to make sure people understand the standard scientific approach to such matters, and it falls to me to explain it, as scientists are under-represented here.

              That is a level of pomposity that you should genuinely feel ashamed of. I would never dream of going over to a theoretical physics forum and begin to tell them how to properly conduct their research and chastise them for what I perceive as deficiencies in their process and conclusions. I know science and I know it very well, but physics is not my field of scientific expertise despite the fact that I actually do know a hell of a lot of physics and the scientific process. That just means I can understand what is put out better than most and can suss out what is garbage from good stuff better than most. That does not mean I have the ability to actually inform how to do new science or draw conclusions in physics. And you do not have the ability to inform the same for fields outside of your expertise whether that is physics or medicine. You hypothetically could, but your writing clearly demonstrates you simply cannot yet.

              Oh yes, one last point:

              where it can be expected to fool many gullible physicians into believing it is science-based.

              Suffice it to say that only expletives of contempt are the appropriate response to this. But it fits in perfectly with your other attitudes about how incredibly much you know that you can come in and say such pompous things. Enjoy that hubris much?

              Perhaps, dear mammalian biologist, you would like to provide us with the references and data to support your claim that physicians are “gullible” and will just accept wholesale whatever we read in certain journals?

              Because what you are describing is medicine as a religion and The Annals as our Bible. Ever heard of a “Journal Club?” Something ludicrously common in medicine where the entire point is for us to sit around and dissect and destroy articles? That would seem to, perhaps just a little, be exactly the opposite of “gullible physicians” being tricked by The Annals.

              And all if this is precisely why we say that you clearly do not know what you are talking about when it comes to medical science and the actual practice of medicine. Because you don’t. And trying to paint us all as gullible rubes in the thrall of whatever the latest literature says is not only stupendously offensive but also unequivocally wrong.

          4. Self Skeptic says:

            Part 4

            Dave said:
            “You have no knowlege of how different the practice of medicine is now compared to 5 or 10 years ago but pull a “20-50 year” figure out of the air.”

            You seem to be suggesting that some great improvement in medical accuracy has been made everywhere else but in my major city and the medical journals, in the last 5 – 10 years, so that I haven’t seen it. I doubt it. To me it looks like business as usual; the diseases that went undiagnosed and untreated in my family decades ago continue to be systematically undiagnosed today. And conversely, the same opportunities to become overmedicated still exist, with a bit of turn-over as to the specific offerings. Most of the same fatally flawed papers are still cited as if they were true, and papers that refute them are still ignored. There hasn’t been any great improvement in accuracy, precision, or validity, that I can see, overall. True, my hypothyroidism would have been diagnosed sooner, so those guidelines have improved. But Lyme disease under-diagnosis is getting worse. The LDL target approach to statins is gone, which is good; but now with the risk calculator has made it into an age game, and more people will be automatically treated, overall, which is bad. The details change, but the basic problem of wholesale confirmation bias, and reliance on chummy groups of experts with COIs, remains the same.

            Have you read a lot, about the history of medicine? 20 – 50 years is not an exaggeration, of how long a typical piece of medical dogma lasts, in the modern era.
            (1)See for example this timeline:
            http://en.wikipedia.org/wiki/Timeline_of_peptic_ulcer_disease_and_Helicobacter_pylori
            (2)Read “The Emperor of All Maladies, with special attention to how Halsted’s radical mastectomy dominated the field, long after he was dead, despite repeated attempts to challenge it. According to Mukherjee, only patient activism made it possible to even do the trial, that eventually demoted it, and even more drastic surgery, from the standard of care in the 1980s. This, even though demonstrations of success from simple lumpectomy (originally a derisive term coined by true-believers in the necessity of radical mastectomy in all cases) plus radiation for early disease, was made as early as the 1920′s. True, the formalities of RCTs hadn’t been worked out back then (and we all know they are still in great need of improvement, to keep them from being falsified.) But even in the 1920s there was still a common-sense understanding that scientific progress requires testing new procedures, and that medicine needs to constantly challenge its current standards of care, to progress.

            If you think that medical science now welcomes advances that change current standards of care, here’s a challenge. Read, or even skim Peter Gotzsche’s book “Mammography Screening” (2012), and think about the medical politics revealed there. The resistance to change has been brutal, from those highly invested in the previous standard of care, and it has nothing to do with quality science. Only Gotzsche’s extraordinary willingness to stand up for the data, against the experts’ asserted dogma, while being repeatedly vilified and censored, allowed any change to take place, and it is still controversial. And only someone with his standing in the international medical and scientific communities, due to the Cochrane Collaboration, allowed his challenge to have any impact at all.
            (Here’s a very short summary of his points:
            http://www.cmaj.ca/content/183/17/1957.full.pdf
            Of course, he could still be wrong, though not from lack of diligence. But his book’s detailed exposure of how the culture of medical science relies upon fostering and even enforcing unwarranted unanimity of opinion, stands as a clear violation of scientific practice. Real science can’t proceed, if dissenters are routinely censored and discredited. Yet in medicine, it’s common.

            You mentioned the HIV/AIDS story; yes, it is wonderful. Take a look at the big role patient activism played in the speed of that triumph. There’s an recent documentary on this, produced by journalist David France, called “How to Survive an Epidemic.” It’s available for online streaming, and on DVD. Scott Holmberg’s book “Scientific Errors and Controversies in the U.S. HIV/AIDS Epidemic: How they slowed advances and were resolved” provides a thoughtful look at the history. Dr. Holmberg was the Chief of Epidemiology for the CDC’s Division of HIV/AIDS Prevention from 1986 to 2005, so he certainly had a front-row seat. Of course, the 1987 classic “And the Band Played On,” by the late activist Randy Shilts, is well worth reading. Journalist John Crewdson’s work on the history of the discovery of the virus is also informative, for those who are ready to have their illusions punctured.

            You also mentioned Lyme disease. That’s not so wonderful. It was discovered in the early 1970s by two mothers (Murray and Mensch) who lived in Old Lyme, Connecticut, and who persisted in bringing the clusters of juvenile arthritis in their community to the attention of public health workers. Then Yale researchers (led by the now-famous Allen Steere) botched almost every aspect of the investigation for years, except in confirming the reports of Murray and Mensch, and in disseminating news about the discovery of this “new’ disease in the US (which did have the benefit of spreading awareness of the disease.) A Swiss-trained government researcher in Montana (Burgdorfer) discovered the causative organism 7 long years later, in 1982, while Steere was still disputing that antibiotic treatment was warranted, despite a history of treating it that way in Europe. After the spirochetal cause was accepted, Steere reanalyzed his previously data, so that it now showed that the antibiotic (at that time, penicillin, as suggested by European and a few US clinicians) helped, while before he had reported using the same data, that it didn’t help.
            This was indicative of a life-long pattern: the literature from Steere, which is foundational to the current disease model, is fatally flawed to a degree that you would surely find incredible, so I won’t even bother describing it here. If anyone here is interested in challenging their belief system about how good peer review and panels of experts are, at weeding out bad science that hurts the public’s health, you can get some hints in Harvard professor John Edlow’s book “Bull’s-Eye”, published by Yale Press, and the full story in journalist Pamela Weintraub’s remarkable “Cure Unknown.” You should, of course, read the original, foundational research cited there, so you can see for yourself that the mistakes were made, and think about how and why this might have happened, and why it isn’t being corrected.

            The limit on how long a piece of dogma lasts, seems to be mostly determined by how long a particular school of experts can dominate a field and keep competing theories from displacing theirs. I’m sure they all sincerely believe in the virtue of their approaches; the problem is that the data often do not support the fervency of their belief. A particularly energetic and stubborn expert can block a field’s progress for a long time, and if he has loyal disciples, it can go on even longer, and get even worse, as Mukherjee says occurred, with the radical mastectomy.

            If you start reading non-triumphal histories of medicine, you’ll find so many examples, that your idea that my “20 – 50 years” is excessive, or that the medical community is any quicker to challenge mistaken but well-credentialed groups of authorities, will quickly be dispelled.

            But I think the mind-set at SBM is the best evidence one could want, that medical culture hasn’t changed in any way, that results in quicker debunking of placeholder fictions. Look at AP, and ask if today’s medical student is prepared to exercise dispassionate, independent critical thinking, regarding current medical guidelines? I don’t think so. As long as that is the case, medicine will largely be ruled by obedience to authority, not by reason or science.

        4. WilliamLawrenceUtridge says:

          SS, the only real solution I could see to address your purported problems would be a massive tax increase the world over to fund greater investment in medical research in order to reach the idealized endpoints you think are egregiously missed. Or, restreaming funding from, say, the military, into medical research. I’d support either option.

    12. Chris Hickie says:

      Where in the heck did you pull those numbers from. As a pediatrician, I can tell you I have to work very hard for what I earn, and it is still at the bottom of the physician pay scale and nowhere even close to the numbers you claim–not even 1/4 of that.

  6. Kathy says:

    “Never back down” and “Be innovative”

    Lovely use of the English language, hmm, and very illuminating. It gives an insight into how sCAMmers see themselves … Tough, rugged individuals that never step away from a fight … and who can think up a creative, original way around any problem.

    It’s so much more acceptable than “Be pigheaded regardless of facts” and “If you don’t know, then just make it up”. Flattery, especially self-flattery, is as delicious as chocolate.

    And Dear, oh dear, how COULD you be so nasty as to call such fine folks scam artists, and rubbish their innovative remedies for all that ails you? Someone MUST be paying you to do this. It’s the only reasonable reason.

    //sarkhasim//

  7. goodnightirene says:

    With a huge percent of the population in some kind of managed care, with doctors on salary, it seems ridiculous to accuse doctors of doing things just for money.

    My doctor is in her 30’s with three small children and a husband who just finished an orthopedics specialty fellowship. They just bought their first house (they were in a modest condo) in a nice, but not top flight neighborhood. They both come from immigrant families. I don’t know if they have educational debt, but either way, I notice that it seems to take two incomes, even for doctors to have a comfortable life.

    Yes, there are “concierge” doctors in NYC, but that seems to be the exception that proves the rule, no?

  8. Alex T says:

    Dr Hall – I’m with you in general. One heuristic I use to sort out real doctors from possible shills is whether they want me to get better or want me to keep coming back for treatment indefinitely. Real doctors routinely pass up money because they appear to value my health (and wealth) rather than their own. That said, you really blew it with this:

    The median net worth for physician households is $700,000 and their median income is going down. The ones who really get rich are those who market bogus remedies or spread misinformation (like Dr. Oz, Andrew Weil, Burzynski, Daniel Amen, Kevin Trudeau, and all the companies that sell diet supplements and miracle weight loss aids). For comparison, the average net worth of American families is $120,000, and the median net worth of the top half of one percent is $1.8 million.

    First, if you’re defending the argument that doctors aren’t rich, taking the 0.5% and the median 0.5% seems like terrible points of reference. Why would you pick 0.5% instead of 1% or 10%? Why would you pick the median instead of the threshold especially since the US has such extreme wealth inequality that the median is likely extremely inflated? It looks like the answer is because any reasonable measurement would have gone against you. At best you are arguing that the median doctor isn’t super-rich.

    According to the Seattle times, “The top 1 percent of American households had pretax income above $394,000 last year. The top 10 percent had income exceeding $114,000.” So individual doctors are practically in the top 1% without a spouse, and solidly in the top 10%. According to Forbes “21.5% of physicians are in households whose income places them in the top 1% of income (versus only 12.8% for lawyers, as one example).”

    I think the evidence is overwhelming that doctors are definitely wealthy and even “rich”. (And as for implication that doctors aren’t rich because few of they will retire with more than $15M…? What kind of insane yardstick is that? Do you have a clue what the median retireee has in assets in the US? All I’m seeing is a defense that doctors may be wealth, they may be rich, but at least they aren’t super-rich. Fail.)

    I also think an argument can be made that their salary can be justified. An argument could also be made that the salary can or should be lower. I don’t know which side would win out, but it isn’t something that can or should be waved away. It certainly isn’t something you’ve even hinted at.

    And as a final side-note, I agree that the sCAMers are far more money-grubbing than doctors and repeatedly make decisions that place their financial health over that of their patients. But is the median sCAM salary any higher than doctors? By discussing the median salary of doctors but ignoring that of chiropractors or naturopaths, I don’t think you’re doing your argument any favours. And I can see why – I’m pretty sure that despite all of their weasely ways, they typically have much lower salaries and lower net worth. What does it say if the noble doctors are making several times that of the alt-med crowd? Again, undercutting your argument.

    Doctors are wealthy. Good. I think they deserve it. I think they come by it honestly and higher salaries does help to reduce some issues like corruption or having to decide between their short-term financial gain or the health of their patients.

    1. Carl says:

      I don’t think you understood any of the numbers you just referred to.

    2. MTDoc says:

      Again, I think you mistake net worth for income. I worked 40 plus years and only broke $100,000 (income) two years. And my net worth (IRAs,etc.) is less than the median 700,000, but is enough to get by without tapping welfare. Physician income is where the government hopes to curb medical costs, but it isn’t what is driving up cost.

      1. Harriet Hall says:

        Net worth is not a measure of income; it is more a measure of how you manage your finances. In the Air Force, my annual income was well below the average for a physician. It never approached $100,000; even with physician bonuses, the highest it ever got was a tad over $80,000. My husband’s income was less than mine (he’s not a physician). We invested, were careful about what we spent, and ended up with a more than comfortable retirement and a net worth substantially above the median for physician families. I once heard a “how to get rich” talk about how anyone could start by simply putting half of their next (and every subsequent) pay raise into savings. When the Air Force announced that it would start paying physician bonuses, I watched some of my fellow physicians rush out and spend the entire amount of the bonus on luxuries before they even got the check. I was already living comfortably on my old salary before the bonuses were announced, so I invested my entire bonus in real estate which I rented to good advantage and eventually sold for a huge profit. I knew of Air Force doctors moonlighting at community ER’s to supplement their AF paycheck at their wives’ insistence that they provide the standard of living they thought a doctor’s family was entitled to. Right now, we could go out and buy any car we wanted, but we drive a well-maintained 15-year-old Chrysler minivan and a 12-year-old Volvo and are perfectly satisfied with them. I define “rich” not by how much money you have in the bank, but by the security of knowing you can afford everything you need plus anything you really, really want.

        1. MTDoc says:

          Agree with your philosophy completely. Childhood without electricity or indoor plumbing helps shape ones idea of wealth. My big paychecks were from salaried practice, actually management, not private practice. Often wished I’d stayed in the USAF, as I loved being a Flight Surgeon, but 14 more years seemed like a long time to me at the time. Besides, my hospital commander at the time was a jerk. I actually got called on the carpet once for getting back late from a flight, even though the reason was our plane got blown off the runway while refueling at George AFB, and they had to send in a new landing gear. No regrets, but one sometimes thinks about the path not taken.

        2. Chris says:

          We derive our income from one lone engineer. Our net worth is more than the average you mentioned, but mostly due to buying property in a little known neighborhood that for some reason became popular just a few years later. After twenty years our house is now worth more than twice what we paid for it according to Zillow, and we owe a bit less than half of what we paid.

          Of course, we have also been putting into our retirement since starting work over thirty years ago. We drive old cars, and do not live a lavish lifestyle. We lived frugally in college, and tried to continue that after graduating. Our main extravagance is paying for the kids’ college tuition so they are not burdened with student loans.

          Just like the young doctor down the street in a smaller house, older cars and not only the burden of student loans, but having the misfortune of a tree on his property fall onto his neighbor’s house during a windstorm (right after he had gotten an estimate to remove it). I assume in the next twenty years his young family’s net worth will go up.

          I also understand that those who have military careers have varying degrees of net worth. My father was a career Army officer who started out has a private after graduating from high school the last year of WWII (then college on GI Bill, back into Army and to Officers Candidate School after eight years being enlisted). He met too many retired officers who were living trailer parks and on the edge, so when my mother was employed all of her salary was invested.

          By the way, one of those officers who did not invest well was his own father. His stepmother was living on survivors’ benefits when she died, and she left lots of debt for my father to pay off.

          Lesson to all, especially since many employers are stripping pension plans: save, save, save some more!

        3. Kathy says:

          It depends a lot how you were brought up – knew a Canadian doctor once whose father was a martinet of economy and who married someone from a family that was the total opposite. They are divorced today, no surprises there.

          Mind you, he took things to extremes in my opinion. Once he asked if I could mend a T-shirt of his that had torn but after I’d taken a look at it I gave it back. The fabric was so worn it would not have held the thread.

    3. windriven says:

      I would agree with Alex T that Dr. Hall might have chosen better yardsticks but I also think the entire argument is a little beside the point. How are American physicians compensated compared with physicians in other countries. You can read the details of a 2008 study here.

      This study shows that US physicians are generally the highest paid though not breathtakingly so. The study adjusts income for purchasing power parity but does not, so far as can see, adjust for educational cost differences. Using 2003 data, US GPs earned an average of $146k per year. After 8 years of post secondary education and a 3 year residency plus a couple of hundred thousand in student loans that doesn’t strike me as at all out of line.

      All of that said, physicians are an easy mark for politicians; they are the face of medicine, the tip of the spear. There are 800,000 of them spread over a bunch of different specialties. They do not in general do a good job of speaking with one voice. Insurers – a few dozen of consequence, and hospitals – a few thousand, are much better able to focus political pressure (read lots of money) to assure that their interests are seen to in the hallowed halls of Congress.

  9. Lauren Hale says:

    Who sponsors this website?

    1. David Gorski says:

      No one but us and whoever buys our E-books or donates to the project. We accept no pharmaceutical industry funding, if that’s what you mean.

      Now, why did you ask this question?

      1. Lauren Hale says:

        I was simply asking.

        1. David Gorski says:

          That is not an answer. I asked you why you asked that question.

          1. Lauren Hale says:

            You can’t operate without a transparent answer? Oh.

            As for the conspiracist jag, that is logical fallacy. Derailment. Irrelevant, and dare I say… paranoid.

            1. MadisonMD says:

              @LH. Well, the dude seems to have given you a transparent answer to your question. Most folks return the courtesy.

              1. David Gorski says:

                Indeed. I am not optimistic in this case. I am, however, amused how Lauren tries to mock one of our commenters by saying she’s waiting for armchair psychoanalysis and then says that I’m paranoid, which is excellent armchair psychoanalysis. Truly, my irony meter melted down after that one. :-)

            2. David Gorski says:

              @Lauren: Please give a straight answer the question: Why did you ask who sponsors this website? I will continue to ask you this simple question until you give a straightforward simple answer that is not dancing around the issue.

              1. Lauren Hale says:

                A better question: why are the websites’ owner defensive over this question PERIOD and throwing out psychiatric hooha in response.

                My intention is to know where your monies appear from. You answered it with ridiculousness, so we’re done. Got my answer.

              2. Harriet Hall says:

                We are defensive because people keep accusing us of being in the pay of Big Pharma when we are not paid at all for writing. We are donating our time and effort “pro bono” to get accurate, science-based information and clear thinking to the public. If a volunteer at a soup kitchen were accused of being paid by politicians to pacify the under-privileged and maintain the status quo, they might feel a bit defensive too.

              3. David Gorski says:

                A better question: why are the websites’ owner defensive over this question PERIOD and throwing out psychiatric hooha in response.

                That’s easy. People like you keep asking it to try to prove that we are “pharma shills” when we are not.

                My intention is to know where your monies appear from. You answered it with ridiculousness, so we’re done. Got my answer.

                And you appear rather disappointed by the answer. I rather suspect this is because you obviously were hoping that we got some sort of funding that would allow you to dismiss us as hopelessly in the thrall of big pharma. Again, we are not.

                Still, your dancing around a simple question, in marked contrast to my straightforward answer to it, is quite revealing to me (no doubt unintentionally). MY question was WHY you wanted to know, and the answer was obvious. If it was different from what I suspected, then why not give a straight answer, the way I did?

                In any case, compared to the real quacks like Mike Adams and Joe Mercola, we run on a truly shoestring budget because we don’t have the sale of supplements, “superfoods,” and various other sundry items to fund our efforts. Heck, this blog ran on a generic WordPress.com template from 2007 until we finally managed to update it this year, and it’s still pretty simple and not very flashy at all in layout.

              4. Clever Girl’s question was legitimate and y’alls defense was unjustified.

                The narrowed views here would suggest a significant bias and one that is not logical = paid to distribute foolishness.

              5. Harriet Hall says:

                She asked a legitimate question and was immediately given a legitimate answer. Then Dr. Gorski asked a legitimate question of her and she did not answer. Then he went on to explain why he asked. What is “defensive” or “biased” about that?

              6. WilliamLawrenceUtridge says:

                Clever Girl/Lauren Hale’s question was not a good one, it’s the automatic, knee-jerk reaction of people who don’t like what they are reading but can’t think of a reason why it might not be true.

                The reasoning is:

                “Your information contradicts what I believe, I can’t find a flaw in your premises or conclusions, therefore you must work for the drug companies.”

                It’s an ego-saving effort to overcome her failure to respond rationally by positing a non sequitur.

                The authors of the webpage aren’t “defensive”, they are irritated at the low level of reasoning and discourse that accusations of bias bring to the discussion. At least, that’s my interpretation. It’s disheartening to see the same stupid, lazy responses again and again from people who are outraged but don’t bother to do the research.

          2. goodnightirene says:

            OMG! Dr G, you sound like my father right before he would knock me across the room for some trivial infraction. Perhaps she was JUST WONDERING. Stop with the Inquisition already.

            1. goodnightirene says:

              All right, she’s weird–I retract.

        2. Lawrence says:

          You really are dense, aren’t you Lauren?

          What about his answer didn’t you like?

          1. Carl says:

            The part where he provided information she wasn’t hoping for.

        3. WilliamLawrenceUtridge says:

          Just asking questions? Becuase usually people who are “just asking questions” that don’t specifically relate to the topic at hand are looking to spread doubt while cloaked in plausible deniability.

          Any chance you might have something of substance to add or ask?

      2. Darwy says:

        Doubtful. From the looks of her FB profile, she’s a conspiracy theorist and a devotee of the “Health Danger”.

        1. David Gorski says:

          I was trying to give her the benefit of the doubt, but I know very well what she was trying to insinuate. I’ve yet to come across a single commenter asking that particular question who didn’t turn out to be trying to insinuate that we at SBM are somehow in the pockets of big pharma. We are not, of course.

          1. Darwy says:

            I get the ‘shill’ comment a lot, too.

            I’m a chemist. I have no ties to the pharmaceutical industry, yet because I understand chemistry and I’m not scared by all those long chemical names, I’m a shill.

            The lack of basic science literacy in the US is really, really saddening.

            1. Lauren Hale says:

              Patiently waiting for your armchair “psychiatric analysis”.

              1. DevoutCatalyst says:

                How often are you checking back in ?

              2. windriven says:

                “Patiently waiting for your armchair “psychiatric analysis”.”

                Mine would be: you don’t have the aluminum foil wrapped tightly enough. Napoleon XIV can help you with that.

              3. Darwy says:

                What, that you’re a devotee of the “Health Danger” and that you have a poor understanding of science?

                That says it all, to be honest.

          2. Republicus says:

            Haven’t you guys also promoted Goldacre’s Bad Pharma? I imagine that wouldn’t make you too popular with your supposed pharma overlords.

  10. Harriet Hall says:

    The numbers I used were the only ones I could readily find. I provided the link, but it was later down the paragraph and applied to several statements, so was confusing. For convenience, here it is again:
    http://www2.ucsc.edu/whorulesamerica/power/investment_manager.html

    1. weing says:

      There is a more recent update to that. The last paragraph of which is even more discouraging.
      http://www2.ucsc.edu/whorulesamerica/power/investment_manager_2014.html

  11. “SBM are somehow in the pockets of big pharma. We are not, of course.” By default your are part of the problem!!!

    1. And the frightening part is SBM is so narrow minded, smug and sarcastic they have are unwittingly doing great harm to the suffering!!

      1. MadisonMD says:

        And you are doing good by, as you claim, murdering 15% of your patients? Or is that a sick joke? Seriously, you need to get some professional help, SSR.

        1. Oh … y’all can be be sarcastic and be complete knuckleheads but I can use tomfoolery? D-o-u-b-l-e standards.

          Those 15% of patients are so miserable due to failed SBM medicine they actually do with for death as a way out of the suffering. All of you do not care!

          1. MadisonMD says:

            I do care. How many are there? Where are they buried?

            1. I know this is futile but here are a few. Each case is unique so each treatment plan was tailor made for that case. A lot of time and effort goes into this therapy. There are no fixes for these patients just ongoing therapy personalized at their request. http://www.youtube.com/playlist?list=PLi9Pftf1qzEjZ8qdvLT0lQJ3nknhcerwD

          2. windriven says:

            You will find that our sarcasm is rarely aimed at the patient population. I cannot recall having ever read any blog or even comment that disparaged a patient.

            Claiming to shoot some of your patients is pretty disturbing even if it is a misfired attempt at humor.

            1. Carl says:

              But even if we give him the sarcasm exemption, look at what he is using it for. He’s using it as a way out of being responsible for his own patients. If they die, it must be the other guy’s fault. Couldn’t possibly be due to his own incompetence or reliance on fake medicine.

      2. weing says:

        “And the frightening part is SBM is so narrow minded, smug and sarcastic they have are unwittingly doing great harm to the suffering!!”

        Doubt if I will get a coherent answer. How is SBM harming the suffering? Are you the suffering one?

        1. Carl says:

          GRAMPS: Come to my side, little Billy, I fear I may be gone soon and I must tell you something.
          LITTLE BILLY: But of course Gramps, anything for you!
          GRAMPS: As you know, little Billy, I have been suffering a great deal these past weeks.
          LITTLE BILLY: Oh Gramps, I am so sorry for your physical ailments.
          GRAMPS: No, little Billy, it is something far worse than that.
          LITTLE BILLY: Please tell me Gramps, what hurts you so much?
          GRAMPS: The worst thing, my little Billy… OH! But maybe I should not burden you with such a horror!
          LITTLE BILLY: No, please Gramps, please tell us what has harmed you so!
          GRAMPS: Well… OK. You see, the worst part of all of this, is when the doctor was describing my treatment options, he… oh God, he actually told me which options were supported by research and how effective they were likely to be! And that bastard was even so cruel as to tell me which options had fewer side effects as determined by large trials and post-marketing surveillance!
          LITTLE BILLY: Oh Gramps, you have been wronged beyond our worst fears! Tell me this wicked doctor’s name, I beg you, and I will avenge this crime with the most brutality I am able to bring forth!

          – the world according to Stephen S. Rodrigues

      3. Stephen H says:

        What is “medical acupuncture”? Sticking pins into someone until they need a real doctor? I am curious – what do you claim to treat with these pins?

        Maybe you should look at the history of acupuncture sometime, along with the history of acupuncture-related infections.

        Oh wait – I’m being narrow-minded and sarcastic. I should let you tell me how acupuncture is based on science and proven by properly conducted, independent, double-blinded studies. I am also keen to hear how acupuncture has developed and changed over the years, and how it takes into account past failures when developing new treatments.

    2. David Gorski says:

      @SSR: How so? Be specific.

      1. SBM is a necessary part of traditional medicine but it is not 100% effective. If a provider does not use his intellect, wisdom and experiences we all lose because of this truth. Yes, SBM can not give us all the answers. It is in this environment that the aging process allows a person to grow, think broadly and gain insight. The only place you gain this is face to face in the office with patients, so patient outcomes are the objective evidence we use in this regard. Science, technology and all the scientific methods PLUS the wisdom gained over the millennia is actually keeping our healthcare system afloat. We must not discounted, disrespected and marginalize the contributions of common sense and wisdom. We need to use what actually works old or new and spend the time and effort truly answering those questions.

        1. If SBM is the only option big pharma and all the dismantling surgeries are the only option. So are you ready to expand your views or stay ignorant.

          1. Stephen H says:

            Did you actually read the article? Doctors are discarding procedures, surgery and medications that don’t work. They look at the evidence, and where the surgery does not improve the patient’s life they take it off the “to do” list.

            How many acupuncture procedures have you removed from your kit because there is insufficient evidence that they improve the patient’s health? All of them? Or do you choose which studies of acupuncture you should listen to, and ignore those that are not designed and conducted by acupuncturists?

          2. MadisonMD says:

            Our views are already expanded beyond drugs and surgery. Science is a tool. It has nothing to do with drugs and surgery.

            Science-based medicine is often used to test interventions that do not fall into the categories of drug or surgery. I am currently participating in 2 studies of interventions that are neither drugs or surgery. I am participating in 2 others that, if successful, will decrease the number of people who receive drugs.

            You have already had a description of a research study that will decrease knee surgeries.

            Your idea that SBM=drugs+surgery is silly. It’s actually much simpler ANYTHING that works is admitted into medicine. ANYTHING that doesn’t work is rejected.

            1. If you guys would ask the proper question we could make progress in healthcare!

              Science is a tool and in your hands it is misused to treat unique individuals. People are not numbers or widgets or molecules. Something is broken and part is the self deceived human element of science based medicine methodology.

              I know you must be kidding about the rejecting anything the doesn’t work.
              Knee surgery, the vast majorities are not needed. Same with hip, back, neck, shoulder, elbow and wrist. Statin over utilization. opiate over utilizations, DMards for RA. Stents. Cardiac cats., Antibiotics, EKGs, Chest xrays, gee x rays in general. Epidurals steroid injection. Rhizotomies. Routine blood testing. etc. One of my patient just had her appendix removed … because it was the standard of stupid care, it was normal. Thank you scientist!

              What is the plan for those who fail your vending machine medicine idea?

              How do scientist get data? From clinicians!!! Who y’all despise, don’t trust, are dumb, make too much money, jealous because you are not making a lot money or did not get into med school.

              I truly don’t think you guys know the harm you do. Sad and frightening. It is almost like you guys are like the scientist who work for the Germans and Hitler, brainwashed, never looking forward or backward, not even inside, just at making sure the data fit the ideology.

              1. Chris says:

                So what is your cure for obstructive hypertrophic cardiomyopathy?

                Tell me exactly why it was a waste of time and money to go to the Mayo Clinic to get the extra heart muscle that was almost blocking the aortic valve removed. Was it foolish for them to put him on a heart/lung machine, empty the blood from his heart and using the image from a transesophageal echocardiogram actually scoop away the extra muscle?

                Then he still needs to take beta blockers because the electrical system of his heart cells are still arranged in an erratic fashion.

                I really want to see what your fantastic solution is to this genetic cardiac condition. Come on, provide us the chiropractic literature that illustrates how much better it is for something that occurs in one out of five hundred persons in the population. Oh, and is the most common cause of sudden cardiac death for young athletes.

              2. windriven says:

                I’ve tired of you and your incessant inchoate rambling. We’ve addressed your questions, all variations on a vapid and exhausted theme. There is no discussion with you, only baseless claims and a fog of meaningless words.

                Do you have citations to support any of these or is this more of your magnificent clinical experience?:

                Knee surgery, the vast majorities are not needed.
                Same with hip
                back,
                neck,
                shoulder,
                elbow
                and wrist
                Statin over utilization
                DMards for RA
                Stents
                Cardiac cats

                A couple of these – DMARDs for rheumatoid arthritis for example – leave me in wonder and disbelief. Where did you get your MD? Are you actually licensed as a medical doctor in the state in which you practice?

              3. windriven says:

                As a follow up – do you practice in the United States?

              4. MadisonMD says:

                It is almost like you guys are like the scientist who work for the Germans and Hitler

                Ah, anyone who doesn’t agree with SSR is apparently akin to a Nazi scientist.

                Of course, the Nuremberg code was designed in response to the Nazi medical atrocities. Let the reader judge who is skirting closer to violating it.

                Says SSR:

                Once a physician gets a diploma and license we actually have a legal right to experiment with people’s lives.

                Relevant portions of Nuremberg code:

                1. The voluntary consent of the human subject is absolutely essential.
                2. The experiment should be such as to yield fruitful results for the good of society… and not random and unnecessary in nature.
                3. The experiment should be so designed and based on the results of animal experimentation and a knowledge of the … disease.
                8.The experiment should be conducted only by scientifically qualified persons.

                Of course, subsequent ethics and federal code has additional requirements for human experimentation, including review by a Scientific Review Panels and an Institutional Review Boards.

                Rodrigues: I’d really like to know how you adhere to the Nuremberg Code and HHS regulations for human experimentation. But the most basic question is: do your patients aware that you are performing experiments on them?

              5. MadisonMD says:

                Windriven: He’s licensed to practice medicine in Texas. You can look it up here.

              6. MadisonMD says:

                Allow me to restate:

                SSR: Do your patients know that you are performing experiments on them?

              7. windriven says:

                @Madison, et al

                This thread is becoming a game of whack-a-mole where Rodrigues is the mole but he appears in a hundred different holes. He asks a question, it gets answered, and he’s off somewhere else. If he gets asked a hard question – poof! – he’s gone and pops up in yet another hole.

                It should be clear that this is not a conversation about science, patient care, legitimacy of psuedotherapeutic practices, or anything else that can be approached with logic and reason. This is about feeding the delusions of a guy who has no understanding of science and questionable competence as a clinician.

                In this scenario there can be no clarity, no resolution, only meaningless motion.

              8. Physicians practice medicine! That is what we do! When we make an assessment that is a guess! We make mistakes and lots of errors! We are humans and thank goodness we really do not need to be 97-100% accurate like a machinist on a lathe. We have an ally who saves us from ourselves. We discount our ally just to elevate our status in society. Thank goodness our ally is not judgement, resentful and will never forsake us.

                Of course modern medicine has made profound advancements which is actually what lulled us into a sense of false abilities. I do see things differently and I do live in the real live world of real live patients who you have to have a relationship with. They are not just numbers.

                My view from downstream from all the researchers is that I have a lot of questions about the neglected and toxic souls that walk into my office. Yet I get no one asking me the correct questions.

                Why is the site here in the first place?
                What is your intent?
                How do you wish to help all of medicine?
                What do you do with the failures of traditional medicine?
                If the site is strictly about the scientific studies, please leave alternatives alone because it is not what you think it is from living in a blinded and/or 2 dimensional world.

                Maybe these questions should be directed at the founders of this site.

        2. weing says:

          No, unlike you, we don’t pretend to have all the answers. We cannot help all who are ill. We try, but we inevitably fail with some. Some require the tincture of time to return to normality and want hand-holding during this period. Unfortunately, we can’t always provide this. That is what I think you are actually providing. Entertainment, while time does it’s work. Your needles, etc, have been tested, found wanting, and abandoned.

          1. You must be delusional to talk about time which is nature and then don’t understand needles. Who are you?? What is your background so I can talk to you on your level.

            Yes we can help all who are ill!!!
            Who told you that we can’t? That’s the only reason I am here is to let you know there are other cost effective ways.

            You are telling me that a tool I use everyday for 15 yrs should be abandoned??? You cant give me an accurate definition of Acupuncture. Why because it needs a few modern definition!! or what a needle does.

            1. Chris says:

              So how can acupuncture cure obstructive hypertrophic cardiomyopathy?

              HCM (not all are obstructive) affects one out of five hundred. What is you treatment to prevent sudden cardiac death? What is your diagnostic criteria? How do you prevent tachycardia? And for someone who has both HCM and migraines, how do you distinguish the difference between a stroke and a complex migraine?

              Seriously, what do you do when someone complains of heart issues, numbness in their left arm and then stops being able to speak coherently? The speech being so odd that the 911 operator recognized it when she heard him over the phone, and he was across he room.

              Come on. This has been my life. Seizures, Croup causing him not to be able to breathe. A speech severe speech delay. A heart condition that could kill him at any time. Migraines that mimic a stroke. And a psychological decay starting at puberty that almost mimics autism.

              What does your vaulted medical training know more than our family doctor, the pediatric neurologist, several speech/language pathologists, a psychologist, the university medical center, the regional heart center, and the Mayo Clinic? Do tell me.

              Should I consult one of your professional brethren in Seattle, or just go with my plan to work with a guardian trust expert? I need answers to real problems. What do you have to say?

            2. weing says:

              “Yes we can help all who are ill!!!”
              A woman with metastatic breast cancer, ER, PR, and HER2 allnegative, with liver filled with mets and ascites and not responding to chemo. Other than comfort measures, you really can’t help her. The patient with advanced Alzheimer’s, who’s forgotten how to walk, speak, and swallow. You can help him/her? I can’t. The patient with advanced macular degeneration. You can restore their vision? The patient with advanced HIV, cerebral toxo, and respiratory failure in the pre-HAART era. Advanced pancreatic cancer patients. Only comfort measures helped alleviate their suffering. The patient with advanced ischemic cardiomyopathy. Those are just a few that I have tried to help over the past 30 years of practice. The last one was lucky enough to get a heart transplant and is doing OK for the past 2 years thanks to SBM.

              1. Compassion and hope devoid of dogma goes a long way.
                Cancer:
                Acupuncture, dry needling and supplements esp magnesium help with the pain, nausea and cancer med side effects. You don’t have to do this at all because the AMA and biased scientist and researcher deny. Now that I know they are helpful, it would be malpractice and inhumane not to.

                Failed surgeries?
                You just let them sink into misery? Poor souls your patient.

                Arthralgia, RA, DJD, FM;
                Release via travell protocols and Acup + dry needles + supplements esp magnesium.

                Macular Degeneration has an acupuncture protocol;
                http://reverseamd.com/santafeprotocol.html

                The list is long …

                You now know the traditional box is a myth and this site is a farce.

              2. weing says:

                “You just let them sink into misery? Poor souls your patient.”

                Does this answer your question?

                “Only comfort measures helped alleviate their suffering.”

              3. weing says;
                What do you do with all of your failed orthopedic surgery cases? Do find an alternative? do you just let them suffer the consequence of mainstream medicine?

                comfort comes in many forms and if you close you mind to them, you are contributing to the problem.

                Who are you? It is like i’m conversing with a non-existent avatar or sock-puppet. please email me at drstephenrodrigues@msn.com we can truly meet and become familiar with how we can help our patients.

        3. windriven says:

          “SBM is a necessary part of traditional medicine but it is not 100% effective.”

          1. No idea what ‘traditional medicine’ means to Stephen Rodrigues
          2. No one here ever claimed that SBM is 100% effective. That would be ludicrous.

          ” The only place you gain this is face to face in the office with patients, so patient outcomes are the objective evidence we use in this regard.”

          Statement like this are why you scare the sh*t out of me. You clearly do not understand the difference between subjective and objective, nor any of the biases that make the subjective so unreliable.

          Patient interaction and clinical experience are essential in arriving at a diagnosis. But treatment should follow science and evidence. Anything else is just experimentation.

        4. David Gorski says:

          SBM is a necessary part of traditional medicine but it is not 100% effective. If a provider does not use his intellect, wisdom and experiences we all lose because of this truth. Yes, SBM can not give us all the answers. It is in this environment that the aging process allows a person to grow, think broadly and gain insight. The only place you gain this is face to face in the office with patients, so patient outcomes are the objective evidence we use in this regard. Science, technology and all the scientific methods PLUS the wisdom gained over the millennia is actually keeping our healthcare system afloat. We must not discounted, disrespected and marginalize the contributions of common sense and wisdom. We need to use what actually works old or new and spend the time and effort truly answering those questions.

          A lot of straw men in that paragraph, I’m afraid. No one here claims that SBM is 100% effective or that it is the be-all and end-all. As for “common sense” and “wisdom,” well, common sense isn’t always so common. If it’s rooted in scientific understanding it allows for the judicious choice between different SBM modalities based on the patient’s situation and desired. If it’s not, it’s easy for “common sense” to be taken in by CAM.

          1. Define Science without using your thoughts and agreement based on human ideology?

            What you guys wish for in not based in reality and does not exist.
            It is full of failure and errors. What do I do when a few of my patients, say 50 / 15 yrs failed back or knee surgery. What would you do if you were their provider? How would you manage them? Do they get money back? Pain and suffering settlements? Are these cases followed to use to expand on a prior study? NO!

            If you are only concerned with old published data points, then that is just the beginning of the science methods. You have to repeat and duplicate and verify otherwise a study is just an option or a isolated conclusion.

            What you guys are up to is using the word “science” to describe non-reality or real life research to justify dogma … that is what zealots and bigots.and despots. If you are unaware that that is what you are doing that is a delusional state.

            1. windriven says:

              Would you please try to focus your thoughts and ideas? Your mish-mash of questions, comments, filosofy*, and insults makes it quite difficult to figure out what you’re saying, much less formulate a response.

              Science, in a very small nutshell, is the organized process of recursively observing, hypothesizing, testing and theorizing about the characteristics and behaviors of phenomena. Testing involves not only the experimental setup, execution, and results but sharing the experimental design and parameters so that others can search them for flaws, suggest improvements, and duplicate (or fail to duplicate) the results.

              “What you guys wish for in not based in reality…”

              Science is entirely based in reality. Your assertion is nonsense.

              “What do I do when a few of my patients, say 50 / 15 yrs failed back or knee surgery.”

              First you would determine what the original problem was, what the intervention was, what the failure mode is, and then treat that
              failure according to the best science available, not ‘well let me stick a fork in your eye and see if that helps.’ Or you could refer the patient to a competent orthopedic surgeon for surgical revision if that is indicated.

              “Are these cases followed to use to expand on a prior study?”

              That is not a study, that is a case report. Studies are not generally done ad hoc. Case studies can lead to observations that can stimulate hypotheses that can lead to studies and that is how science gets done.

              The rest is indecipherable to me other than the odd insult.

              *I use this spelling not to mock Rodrigues’s language difficulties. Were I to attempt to communicate in whatever his first language is I would certainly do much worse. I use the spelling because what passes for his philosophy would not be recognized as such by any sane philosopher.

              1. Ken Phelps says:

                Focus his thoughts? The phrase “Gish Gallop” would seem appropriate here.

            2. Darwy says:

              As someone who has had reconstructive knee surgery and is on 10 years post-op – what will I do if it fails? I’ll see what can be done to fix it.

              I don’t anticipate it just ‘failing’ without cause. A sports injury, a slip, a fall, an accident – those all have causes.

              That’s how the original failure occurred, by the way. A skiing injury.

              I went 16 years without having it attended because I didn’t like the options which were available to me at the time of the injury – and then I learned to adapt without a functional ACL present in the knee.

              When my adapting wasn’t good enough for mobility purposes, I had it reconstructed – using a method which I believe was the best option given to me.

              There’s no reason my knee will ‘fail’ barring another injury. My OTHER knee …. I’m anticipating needing that scoped and possibly fixed after the holidays. Not because it simply ‘failed’ – but again, because I had a nasty fall and the general treatments (R.I.C.E) haven’t lessened the issue.

              It’s evidence based medicine. What procedures are proven to work, what procedures are most (or least) invasive, etc.

              1. If you think a human can fix your knee problem with a scalpel or scope, fine live in that delusional state. I can’t even get a mechanic to fix my car, the first time and it’s strictly mechanical and metal. What the surgeon is doing is perpetuating fixing your knee and nature fills in the for his arrogance. I have seen countless fixed knees, shoulder, hips that failed but myofascial therapy helped to stabilize the joints and the pain.

                NObody here wants to know a different way just keep marching the victims into the gas chambers. Surgery will work for all the wrong reasons. Some surgeries are a marvel most are not and I know why. Hey guys you can help stop sending most of those victims across the river full of gators. Some will make it some won’t

              2. MadisonMD says:

                I can’t even get a mechanic to fix my car, the first time

                Have you tried needles?

                NObody here wants to know a different way just keep marching the victims into the gas chambers.

                Gas chambers? Now what in the blazes are you talking about? You are the one who believes you have a license to experiment with peoples lives.

        5. Harriet Hall says:

          Of course SBM is not 100% effective, but it is far more effective than any other method, including yours. Using trial and error without controlled observation is highly likely to mislead you. You fail to distinguish between the experience and wisdom gained by a clinician over the years and the “in my experience” claims that are the most dangerous 3 words in medicine. For the difference, please see http://www.cfah.org/blog/2011/guest-blog-the-role-of-experience-in-science-based-medicine. I know this distinction is over your head, but I am providing the link because other readers may benefit from it. We are all clinicians like you; I was in family medicine. The more patients I saw, the better I got at diagnosis and pattern recognition; but there was no way I could possibly get better at guessing which unproven treatments might work better than placebo. If I had tried acupuncture I probably would have been just as misled by apparent successes as you have been.

          1. You are delusional to think that a research paper is just as valid as clinical outcomes and should be used as a gold standard.

            Who paying yall to think like this??

            1. RealityEngineer says:

              re: “research paper is just as valid as clinical outcomes”

              A research paper is a vetted codification of clinical outcomes. Anecdotes and small numbers of cases can be easily misleading, Somehow I doubt you are referring to doing rigorous statistical analysis or double blind testing of the clinical outcomes you see.

              re: “Who paying yall to think like this??”

              People might just as well ask who is paying you to show little evidence that you understand how to evaluate evidence or of the scientific worldview that modern medicine is based on.

              Learning to understand science and statistics can be difficult for many people, apparently some doctors care too little about their patients to go through that process.

              I find it very disturbing that you appear to have somehow actually managed to graduate from a medical school and become a practicing MD with the mindset you exhibit on this page (and more disturbing of course that some high profile docs like Dr. Oz similarly exhibit such poor reasoning skills and have a wide audience).

              I find it disturbing that anyone with such poor reasoning skills is able to practice medicine, and that people are paying you for medical treatment. However I suspect you are unwilling to even consider the possibility that the vast numbers of doctors that have a more scientific worldview than you appear to, might possibly know something you don’t. Obviously reality isn’t determined by how many experts believe something, but it should indicate that it is at least something worth learning about before dismissing out of hand the centuries of progress in medicine that were driven by the scientific method. (directly, and even in directly in the development of the science behind all the technology in use in modern medicine today, including that underlying the computer you use to read this).

            2. Harriet Hall says:

              “You are delusional to think that a research paper is just as valid as clinical outcomes”

              Your thinking is hopelessly confused. You can’t compare “a research paper” to “clinical outcomes.” A research paper is a report of an experiment to test clinical outcomes from a treatment, to find out whether they are better than the outcomes from a placebo. It is not valid to just try something, interpret the patient’s response yourself, and conclude that your treatment is effective. You have even agreed with the list of factors that can lead us to false conclusions. You just don’t seem to understand that the list applies to you. Science is a tried and true toolkit that helps us compensate for human errors. It is delusional to think you can avoid those errors without using scientific methods. Perhaps you grandiosely imagine you have some kind of unique superhuman intelligence.

              “Who paying yall to think like this??”
              We have explained repeatedly that we are not being paid by anyone. Why do you not believe us? Are you accusing us of lying? Can’t you imagine any other reason for thinking other than being paid to think? Who is paying you to think like you do?

              1. Kathy says:

                Dr Hall – “Science is a tried and true toolkit”.

                SR, when you try to do medicine using “in my experience” in preference to data from properly constructed, published trials, you are trying to change a flat tyre using a knife and fork. How about changing your toolkit? Seriously, man, a jack and a wheel spanner work so much better.

              2. This is not about me but an entire discipline parallel to traditional medicine that works and is safe. I’m just the stubborn messenger and practitioner defending the Acupuncture as it related to Myofascial Release Therapy with hands-on and needles.

                NOT grandiose just practical and safe and effective.

                Give me the link of a medical paper that has be repeated to find the same results and conclusions. Then a paper that has been repeated more than twice. Then I will consider that study of vital importance.

                http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020124

                http://www.smartplanet.com/blog/smart-takes/is-the-scientific-method-seriously-flawed/

              3. Harriet Hall says:

                SSR says “This is not about me but an entire discipline parallel to traditional medicine that works and is safe.”

                Here we have the essence of our disagreement: traditional medicine that “works.” SSR is happy to define “works” as “patient reports feeling better,” or “I think patient has improved.” Science has learned from long, hard experience that most things that “work” by that definition don’t “WORK” any better than a placebo.

                SSR: please explain why bloodletters could be so wrong when they were so convinced that they were right for so many centuries, and why you believe you are exempt from similar errors?

            3. Stephen H says:

              Hint: the plural of anecdote is not data.

            4. RealityEngineer says:

              Poorly designed software won’t let me reply to a post of yours below. Real science and understanding statistics and the nature of evidence isn’t easy for many people. Humans existed long before people learned science and saw it advance to its current state since the rigors of thinking this way aren’t easy for many, and it takes tie. I’d suggest you consider whether you were the smartest person in school, or whether there were those that were better at math and science. I’d suggest you consider whether perhaps those type of people might potentially have figured out more about what works and what doesn’t than you do, that perhaps you aren’t smarter than all the myriad scientists and western doctors that value science based medicine.

              It is emotionally appealing to think that somehow you have the “answer” and are magically now smarter than all those people when you weren’t in school, but consider whether the odds are better that they understand things that you refuse to take the time to understand. I’d suggest you consider caring more about your patience than about boosting your ego.

              The majority view can turn out to be wrong, reality isn’t determined by a vote. However those that overturn older views in science are expected to understand the existing views in order to disprove them and to be sure they are wrong. You show no evidence that you actually understand science based medicine. I’m actually amazed that the standards are so low that people with the sort of views you express are able to become MDs and be licensed to practice medicine. I’m even more shocked that you have the arrogance to think you know more than those that do understand it, despite the fact that you show no signs of understanding the nature of science and evidence.

              1. RealityEngineer. People are not Xs and Os or numbers or widgets or set chemical structures. Can you comprehend that flesh and blood and human uniqueness make designing a study very difficult? A computer and it’s programs work 100% of the time in a consistent and predictable way. NOT humans.

                Placebo is not the best Standard. IMO, there is not a good way to factor in or out innate healing due to the variability in human design. Most of the benefits seen in a study are on the back of placebo or just natural healing. Can you tell the difference? Please don’t perpetuate what a scientist finds in a study and extrapolate it to humanity.

                Who are you? It is like i’m conversing with a non-existent avatar or sock-puppet. please email me at drstephenrodrigues@msn.com we can truly meet and become familiar with how we can help our patients. or add a link to your credentials for verification.

              2. WilliamLawrenceUtridge says:

                …except people kinda are Xs, Os and widgets. Very, very tiny widgets that interact in complicated ways, but basically we can be seen as larger machines composed of many, many tiny machines. And people are unique – but are also built on the same basic building blocks, with different flavours and complications. Personalized medicine is an effort to discover objective markers of those flavours and complications to account and adjust for them, rather than being forced to rely on group-level data required to determine causality in contemporary research.

                What you are really asking for is an excuse to keep practicing medicine without adaptation or improvement, to rely on soft endpoints and patient satisfaction, and basically charge your patients for getting better on their own while you hold their hand. You’re like a phone sex line, but for medical problems.

                Your continuous claims of “you can’t comprehend my medicine” is really just a nonspecific, knee-jerk reaction to avoid having to recognize that what you are doing appears to impovrish your patients while doing nothing to help them. You use it to discount and ignore the scientific literature so you don’t have to engage with it and confront your failings as a doctor.

        6. WilliamLawrenceUtridge says:

          SBM is a necessary part of traditional medicine but it is not 100% effective

          Medicine, in fact, nothing, not even bridge building or the orbits of comets, are 100% anything. If your criticism is that medicine is not perfect – take it up with God, who decided to have humans evolve rather than crafting a perfect meat sack to carry around our thinking machines. Medicine acknowledges it is imperfect, that is why it keeps doing research and revising its teaching and practice. In fact, a major drive in medicine has been recognizing and conveying to patients the imperfection of medicine, in the form of greater patient consent and reduced medical paternalism. In many ways to its detriment, as all that informed consent engenders significant worries about incredibly rare risks, and reductions in placebo effects that accompany a confident, unqualified opinion by a man in a shiny coat. Real doctors are hampering their ability to reduce suffering by insistence on honesty, meanwhile CAM promoters are deliberately lying to their patients to enhance placebo effects. Who is the ethical party in that situation?

          If a provider does not use his intellect, wisdom and experiences we all lose because of this truth. Yes, SBM can not give us all the answers.

          Straw man, on this very blog the art of medicine is recognized – along with the recognition that the art must be informed by science. Sadly, in order to effectively determine causality, one must conduct research on groups of people to account for natural healing; this of necessity leads to group-level outcomes that obscures individual healing. Unfortunately, there is no better way to do research at this point. If you’ve got a better way to improve outcomes overall, please suggest it. Personal experience is a blind alley into arrogance and patient deaths, as “personal experience” was what justified homeopathy, bloodletting, and the avoidance of antiseptic surgery and childbirth.

          Science, technology and all the scientific methods PLUS the wisdom gained over the millennia is actually keeping our healthcare system afloat.

          The only thing ancient wisdom really provides is the recognition that patients get better with time, or die, and that a confident doctor has its own healing power. Patient outcomes and general health improved thanks to the jetissoning of the remaining “ancient wisdom” like “the brain exists to cool the blood” and “women can’t be trusted to think logically becuase their uterus wanders inside the body”.

          We must not discounted, disrespected and marginalize the contributions of common sense and wisdom.

          If common sense and wisdom actually improve patient outcomes, we will see this demonstrated in controlled trials. What you’re really asking for is an excuse to avoid having to change your existing habits and practice. What you’re asking for is (ironically given your statement about growing, thinking and gaining insight) permission to never have to change your mind, to never have to grow, to never have to admit error.

          Keep it up and eventually you’ll be hit with a malpractice suit (assuming you even have a medical degree, since you’ve never disclosed what type of doctor you are).

  12. Ben says:

    I definitely support the thrust of the article, but I’m a bit disappointed that you essentially published an anecodatal opinion-piece on a site that values evidence and experiment.

    Healthcare costs are rising, so it’s reasonable to ask if “physician greed” plays any role in this. “Will physicians perform unnecessary services primarily for more money?” is a big question in health economics research.

    An evidence-based look at the question of physician greed will show that studies do suggest that physicians will sometimes “induce demand” for unnecessary services, just to make money.

    Here are just a couple of links to get you started:
    http://theincidentaleconomist.com/wordpress/demand-inducement/
    http://content.healthaffairs.org/content/29/4/683.short

    None of this supports typical CAM conspiracy theories. Physicians clearly don’t do it ONLY for the money. But if we’re truly going to be self-reflective and critical as physicians, we need to recognize that money is a big part of the job and does influence us.

    1. MadisonMD says:

      Ben, you make some good points here. Our current system preferentially reimburses procedures over general medical care. Physicians, especially in procedure-based subspecialties, tend to earn more than non-procedure based specialties. This has often tipped the balance against primary and rural care and has contributed to poor access to care in many communities. Nobody wants a paycut, but it is a fair question to ask whether physicians earn too much (especially top earners).

      I agree with you that health economics must change. I am disappointed to find that, as Greg pointed out, Canada has the same problem– I found this article after looking at Greg’s post. The radiologists stand out, but when sorted by salary, they are actually buried in a long list of hospital administrators.

      All these folks work hard, but do hospital CEO’s and specialists deserve to make 3-5 times that of a community-based primary care physician? As a hospital-based specialist myself, I say no.

      1. SBM is why this discussion is going on; no logic or common sense and no self-reflection. Y’all have been here so long you can’t see the forest for the trees.

        1. MadisonMD says:

          No self reflection? You clearly have not read or have not understood. Again.

        2. Sawyer says:

          SSR, we are DESPERATE for more people to join the discussion that could initiate more self reflection. I occasionally get uncomfortable with the lack of diversity in opinion on this blog. I’d love to have my viewpoints challenged more often, as I’m sure most of the authors and commenters would. The problem is that every single person that comes offering an alternative viewpoint plants the goalposts so far into quack territory that we can’t even begin to engage them. Have you ever tried talking with a group of people where 99% of them don’t know what they are talking about? That’s what most of us feel like. Can you point me to a single issue in the history of science where this communication tactic worked?

          1. You want more to think like yall … I hope none exist. And I hope yall have no authority to inflict the dogma on society.

            Please stay here and don’t touch a patient. The keyboard and monitor are the only place for yall.

            1. Stephen H says:

              Dr Rodriguez, I would like to recommend some reading: Gulliver’s Travels, by Jonathan Swift.

              1. Upset you did not get into med school so you nitpick to feel good about yourself.

              2. WilliamLawrenceUtridge says:

                Ignore any dissenting scientific literature to avoid recognizing just how much of your patients’ money and time you have been wasting with ineffective interventions.

                I didn’t go to medschool, but I can think critically enough to realize why science is a better guide to reality than personal experience.

                What kind of a doctor are you Stephen?

      2. windriven says:

        @Madison

        “[The Canadian] government’s intention to cap salaries for new employees in the broader public sector – including hospitals – to $418,000 a year”

        By way of perspective, the President of the United States is paid $400,000 per year.

        1. MadisonMD says:

          I’m with you, windriven.

  13. weing says:

    It’s hard to help those with imagined illness. Only imaginary therapy, as provided by you, can help them. We have to deal with real illness.

    1. windriven says:

      Well said, weing. I’ve lacked the stones to make that comment myself because it will likely be misinterpreted to suggest that all patients with intractable pain or illness are malingerers. The closest I cam was asking SSR what his success rate was with Morgellon’s. Of course I didn’t get an answer. Go figure.

    2. MadisonMD says:

      @weing
      Medicine does need to find a way to deal with these patients and not just cast them aside. Just because we cannot make a diagnosis doesn’t mean someone is not ill. I genuinely feel sorry for those in pain, those with undiagnosed illness, even if they believe they have an illness that they don’t have.

      At my hospital if someone calls the ID department complaining of Chronic Lyme, they get an appointment with Integrative medicine. If someone calls Mayo Clinic seeking a consultation for Chronic Lyme, they don’t get an appointment at all. Some people are misinformed, and I could see how these consults could be considered a waste of effort. But I think turning all these folks away is a bad idea. What if someone is fatigued from hypothyroidism or anemia, happened to look up fatigue on google and then called up wanting to know if they had Chronic Lyme? With a legitimate consult, some might receive an accurate diagnosis and get better. Some may have realized that you don’t have a diagnosis but listened to good advice on managing pain or fatigue. Instead they get quackery.

      You could fairly argue that these patients should go to their primary care provider. That’s really the answer. But we need to improve access to PCPs so their non-life-threatening issue doesn’t get short shrift when the doctor needs to address several health-care-maintenance issues in the same 15 min visit.

      1. windriven says:

        “But we need to improve access to PCPs so their non-life-threatening issue doesn’t get short shrift when the doctor needs to address several health-care-maintenance issues in the same 15 min visit.”

        Amen. It is interesting that visits to primary care physicians is much higher in Europe (healthcare about 10% of GDP) than in the US (healthcare 18% of GDP). I am not suggesting causality. But it is interesting.

        A lot of the fascination with quackery stems, I think, from the fact that quacks have time to burn; they can spend a good deal of time listening, talking, assuring, and so forth. PCPs working in the current US health care model simply cannot spend that kind of time.

        1. Kathy says:

          The other thing quacks can offer is total certainty. They are 100% sure what your problem is and 100% sure they have the cure. People who are unhappy and afraid, whose health, finances and relationships are wobbling, want reassurance that Daddy has it all under control. And they can secure their relationship by pouring mutual indignation on those useless cold-hearted profiteering doctors that couldn’t or wouldn’t help the sufferer.

        2. Gewisn says:

          I’m a bit confused by the term “cannot.” What is preventing doctors from seeing 40 pt’s per day instead of 60 or 80? I had thought most managed care practices were paid a capitated rate, which (if I’m understanding correctly) means you are paid to care for a specified # people, not per visit. If seeing them more slowly and comprehensively reduced the severitý of the illnesses, would that not reduce the need for acute care appts?
          I remember seeing an article by a British PCP group a few months ago about using a “same day only” practice model, that included phone consult as the first step, then making an appt later in the day if that was necessary. The practice was able to care for a larger total # patients, with longer appts per patient, with never a wait longer than same day to see a doc.

          1. windriven says:

            @Gewsn

            “I’m a bit confused by the term “cannot.” What is preventing doctors from seeing 40 pt’s per day instead of 60 or 80?”

            I’m not sure whose “cannot” you’re referring to. Madison was not talking about cannot see x number of patients, he was talking about inability to make a diagnosis with certainty.

            I wonder if you can give a citation for the British group? Then we’d all be on the same page.

            “The practice was able to care for a larger total # patients, with longer appts per patient, with never a wait longer than same day to see a doc.”

            Never a wait longer than the same day? Ever?

          2. MadisonMD says:

            @Gewisn

            What is preventing doctors from seeing 40 pt’s per day instead of 60 or 80?

            Not sure how you arrived at these numbers.

            If you work 8 hours with 15 minute time slots and no breaks you will only see 32 patients. Because of an illness, emergency, or urgent/complicated visit you would likely be spending 30-60 minutes with at least one of these patients, making the rest of clinic run late, and finish clinic in the evening. With breaks, or new patients (these visits are longer), you will see fewer than 32 per day.

            During that day you will also have to spend 5-10 minutes per patient documenting the visit, placing orders/consults (Leaving you with only 5-10 minutes to actually spend with the patient). You will also need to attend to any phone calls. In some practices, you will need to go to the hospital and see any of your patients who are admitted (this is becoming less common with the rise of hospitalists).

            I don’t know of any doctor who sees even 40 patients per day much less 60-80. If it was in the range of 20 per day, then patients would get more time.

            So why not only see 20 patients per day? Usually there are so few primary care physicians for every service area that this would leave most patients unable to get appointments–especially new patients. This is a larger problem in rural areas than in urban areas.

          3. Where have you guys been for the last couple decades. In the 90′s I was incentivised to see 60/day. Easy, all you have to do is say hello and here is your prescription, then on to the next. Please guys get out of your fantasy land. That was the standards we followed.

            NOT me today!!!

            It still goes on.

            1. weing says:

              “That was the standards we followed.”
              Speak for yourself. No wonder. It explains a lot about you. You ran a mill. And you wonder why it’s so difficult to separate placebo from your needles? Because there is no difference between them.

  14. Self Skeptic says:

    There are a lot easier ways to make money than going into medicine. But none of them have the cachet of human service.

    I do think the guaranteed high pay (compared to other highly respected professions like teaching, not compared to the real money-makers like financial manipulation) is one reason why many parents urge their children to become doctors. Nobody wants their kids to starve in a garret. The other reason is prestige. It’s hard to overestimate the call of prestige, for both anxious parents, and for ambitious young people who want to “be somebody.” No one can, or probably should, be self-motivated at the age of 20; and medicine is an obvious choice for those who are academically capable, and anxious to be respected.

    For those who don’t have a natural bent toward service and compassion (which lack I think is revealed by habitual snarkiness), I usually assume prestige is the main motivator. Once you have enough, “money is just a way of keeping score”, especially in the US culture. I think those who assume that most doctors are in it solely for the money, are those who don’t have enough, so money looms large as a potential motivator. Though maybe I’m underestimating the prevalence of greed. I have to admit, there are a lot of people who seem to feel a need for a second house, a boat, expensive cars, etc. And then there are the huge expenses of rearing upper-middle-class children.

    But I think the people at SBM are more like religious proselytizers. They want people to adopt and conform to their belief system, which just happens to support the prestige of their profession. You can tell by all the non-physician followers, that it has as much to do with a belief system, as with money. Someone made the amusing comment about the Skeptic movementin general, that it looks like “a bit of a cult.” Bingo.

    The medical industry, on the other hand, in which most doctors are mere employees, is motivated almost solely by money. It’s a group of corporations (most notoriously big pharma) , who are now regarded as having a fiduciary duty to make the most money possible for their stockholders. Most physicians willingly participate in this industry, and many defend it almost indiscriminately when any aspect of it is criticized; the evidence for that is abundant here at SBM.

    But even those who can see its downside, and would like to practice in a more humane (patient-centered) manner, are prevented from doing so, by the terms of their employment. Haste, renamed productivity, is mandated. Only solo or small-group partnerships can practice independently, with reference solely to thier judgment as to what would benefit the patient. Even then, they may not be able to take insurance, without being co-opted into using the industry’s standards of practice, rather than their own.

    This conflict is resolved for most employee-physicians, I think, by having faith that the industry standards [i]are[/i] best for the patients, usually. I’ve come to doubt it, and I think the valid reasons for doubting it are rather obvious. But I understand the motivation for believing it, from both the physician and the patient perspective. It usually takes one or more bad personal experiences with systemic errors in medicine, to make a person abandon this faith. These errors aren’t rare, but they can be hard to recognize. I think it quite likely that most people hurt by mainstream medicine never even know it.

    If I were to adopt the SBM view of dividing everything into two opposing sides, I’d say the polarization is between true-believers in the benevolence and efficacy of mainstream medicine on one side, and those who have been injured (or just insulted) and have lost faith, on the other. Since “man is the animal who takes medicine,” many of the non-believers turn to CAM. But there are also people who are trying to reform medicine, so it more closely approximates its stated function. Granted, it’s a labor fit for Hercules; but so is the war against superstition that SBM is waging.

    For credibility’s sake, it’s a good thing the family practice doctor wrote this post, instead of the surgeon. But the title gives the impression of protesting too much. Just as “Vaccines work, period” starts me thinking about those that don’t, and CAM atrocity stories start me thinking about mainstream medical attrocities, a title like this might be counterproductive. You’re likely to remind people of a truly skeptical bent, that our doctors might not have their individual patients’ needs at the very top of their priority list (unconsciously, of course). At the top could be money. Or prestige. For established doctors who take those perks for granted, it might be peer approval, legal safety, production goals, or some ideological commitment like SBM or EBM. We patients should keep an eye out, for signs of such distractions, that might be interfering with our care.

    Those of us over a certain age may remember Nixon’s famous “I am not a crook” speech. It didn’t go over too well with much of the public. With hindsight, in light of all the history I’ve read, I guess you could argue that he wasn’t particularly crooked, for the president of a powerful nation facing an election campaign. And maybe most doctors aren’t especially greedy. But calling attention to the possibility may not be a good idea.

    1. windriven says:

      @Selfie

      Oh, where to start?

      “[SBM] want people to adopt and conform to their belief system.”

      “If I were to adopt the SBM view of dividing everything into two opposing sides, I’d say the polarization is between true-believers in the benevolence and efficacy of mainstream medicine on one side, and those who have been injured (or just insulted) and have lost faith, on the other.”

      My goodness, what a dog’s breakfast of ignorance and misinformation.

      Science is not a belief system. Belief is acceptance without evidence. Science is conditional acceptance only with credible evidence. Belief has no role.

      It is S, not SBM, that divides into two sides: that which is supported by evidence and that which is not. SBM does not promote the benevolence and efficacy of mainstream medicine, it promotes the benevolence and efficacy of medicine that has been proven to be safe and effective. Sadly, what is proven and what is mainstream are not always the same. And finally, the opposite of scientific is not “those who have been injured (or just insulted) and have lost faith.”

    2. Sawyer says:

      You’re developing a nasty habit of saying things that people here already agree with and pretending they are your own unique viewpoint. Please stop.

      I’m guessing most of the doctors on this site don’t have much tolerance for coworkers that stumbled into medicine because of their parents pushing them into it, or because they wanted a reliable income source. I’ve met plenty of people in academia that could not stand working with people like this, and they make it a priority to only recruit students with a greater sense of responsibility and excitement for their field. Shockingly, these people are the ones that end up the most successful in the long run.

      1. Darwy says:

        I briefly considered pre-med, etc., before settling on my current degree path. I decided that medicine wasn’t for me, because I have very little patience for other people and a really, REALLY bad bedside manner.

        My degree now gives me the sense of accomplishment and contribution to society that I wouldn’t have been able to obtain had I gone into medicine.

    3. Self Skeptic says:

      Hmm,

      Windriven, not a doctor, says I’m providing a dog’s breakfast of ignorance and misinfomation.

      Sawyer, a doctor, says everybody already knows all the things I’m saying, and I should stop pretending they are are [my] own unique viewpoint.

      These comments from Windriven and Sawyer could hardly be more discordant; they’re almost exactly opposed.

      I guess I’ve hit the happy mean, between the two long tails of judgment. :)

      1. windriven says:

        Ah Selfie, the delusion is strong in you. Or maybe the issue is reading comprehension. I don’t know and my interest is already waning. So the short version is that I, not a doctor, was addressing your misstatements about the nature of science. While Sawyer, a doctor, was addressing your banalities about motivations. Our separate responses make this clear. Yet you take an apple and a banana and pronounce them different. Does your intellectual prowess know no bounds?

        1. Andrey Pavlov says:

          Of course he fails to see that they are not mutually exclusive and that you indeed each approached different facets of why is argument is mundane at base and extends into ignorance. I had attempted to actually bridge the two points in some of my posts to him, but he seems confidently deluded in his Dunning-Kruger.

    4. WilliamLawrenceUtridge says:

      But I think the people at SBM are more like religious proselytizers. They want people to adopt and conform to their belief system, which just happens to support the prestige of their profession. You can tell by all the non-physician followers, that it has as much to do with a belief system, as with money.

      I’m not a doctor, not even close. I just think medicine is fascinating, and I appreciate the fact that these actual doctors take the time to demystify and present their informed analyses of broad and specific medical issues to better-inform my understanding of medicine. For free. Medicine is a profession that deserves prestige (and oversight, and research funding, and regulation, and above all – a federally-funded health care system) because people’s lives hang in the balance, both on individual and population levels. As for the science part, science is the imperfect but best-to-date method of understanding reality. Science can break down with individual patients, science can be wrong, but science also learns – and the more you know about it, the more you understand why it’s better than the alternative.

      Why do you have such contempt for doctors? Why do you think they should be paid the same amount as the average citizen when they must undertake a grueling amount of training and education in order to master just the very basics of what makes people sick and how to hopefully make them better? And why do you claim that physicians “willingly participate” with big pharma, when some of the primary critics of such companies are doctors? Why do you pretend that the blog authors and commentors are boosters for Pfizer when we are so ready to criticize the practices of big pharma (such as, to pick two convenient links, here and here).

      What’s your alternative to a privately-funded drug development system? How will you ensure that this system is efficient and effective given how complicated the human body is and the incredible potential that effective pharmaceuticals have to cause side effects because there are so many overlapping receptors in the brain and gut?

      In your division of the world into two camps, SBM and CAM, why do you spend so much time criticizing SBM and have nary a criticism for CAM? Do you think CAM is effective? Why?

      Why do you reference Dr. Gorski’s post “Vaccines work, period“, as if it didn’t note, in the first paragraph, that vaccines are imperfect (90% effective) and that that imperfection is the very reason why universal vaccination is so important? Why ignore the important nuance in favour of the charicature?

  15. Jean Charcot says:

    Awesome post and long overdue. Thank you.

    I have noticed that those doctors who oppose vaccination are the most likely to be selling *something* as well. Tenpenny, Mercola, Humphries, Blaylock, Toni Bark, Dr. Sears, Dr Lawrence Palevsky, Dr. Kelly Brogan ( she shills for the Fisher-Wallace stimulator) – is there any one of them who isn’t also selling something? Maybe Dr. Jay Goron doesn’t sell anything. But I don’t think any of them take anything other than cold, hard cash. You won’t find those guys working in inner city clinics or underserved areas.

    In contrast, think of the main vaccine/science defenders. Other than books they have written, is there any one of them who is selling anything?

    Correct me if I am wrong. I will ackowledge any errors.

    1. David Gorski says:

      No, even Dr. Jay sold stuff. He used to sell DVDs of his health and vaccine advice. I’m not sure if he does anymore.

      1. Jean Charcot says:

        Thanks David, error acknowledged. By the way, I would love for you to write more about the “next generation” of anti-vaccine doctors like Drs. Palevsky and Brogan (Sayer Ji’s right-hand woman at greenmedinfo by the way). They are in need of some respectful insolence, and their writings are easily found on their websites.

        This is a good start….

        http://sciblogs.co.nz/diplomaticimmunity/2013/08/20/dr-kelly-brogen-and-the-case-of-the-misplaced-science/

        1. David Gorski says:

          I have mentioned Dr. Palevsky before in discussing the antivaccine propaganda “documentary” The Greater Good, in which he played a prominent role.

          I’m not familiar with Dr. Brogan, although I am very familiar with Sayer Ji over at GreenMedInfo.com. Perhaps I should look into her activities in 2014.

          1. Jean Charcot says:

            Well, I think all of most anti-vaccine stuff can be found here:

            http://www.greenmedinfo.com/gmi-blogs/drbrogan%40kellybroganmd.com

            There is more on her personal website and facebook page.

            Or if you really want 47 minutes of torture, there is this:

            http://www.youtube.com/watch?v=QNKDoo-_pDg

            She is worth your attention, David, because not only is she the #1 “Medical Advisor” at greenmedinfo, but she also is the only anti-vax doctor I know with current academic credentials. So people are paying attention to her.

            You do have to carefully read the links in her articles. Very few of them say what she claims they do. She often cherry picks a sentence or two to give a false impression. But what am I saying…..you know how to do this.

          2. Jean Charcot says:

            And last message…..

            Here is what she had to say about Project Tycho on her facebook page:

            Shame on New England Journal for publishing hand-waving nonsense in the service of vaccine propaganda: “Never a gold standard for scientific inquiry, population studies now make up the bulk of vaccine advocates’ clinical arsenal to discredit more factual biological research favoring the arguments of vaccine opponents.”

            She then linked this this:

            http://www.greenmedinfo.com/blog/multiple-infant-vaccines-linked-dramatically-increased-mortality?page=2&utm_content=buffer749e5&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer

            While at the same time saying this:

            Listen up people. Listen to the data, and tell me that you need more information than that presented in this paper to convince you to reexamine the entire premise of vaccination. Kids were 3-8x more likely to die, the more vaccines they received. Read this brilliant analysis “The US childhood immunization schedule specifies 26 vaccine doses for infants aged less than 1 year-the most in the world-yet 33 nations have lower IMRs.” The study found that there is a highly statistically significant correlation between increasing number of vaccine doses and increasing infant mortality rates.”

      2. Jean Charcot says:

        I acknowledge the error.

        By the way, David, I would love for you to apply some respectful insolence to the next generation of vaccine-denying docs. Drs. Palevsky and Kelly Brogan are some examples, whose website will supply a wealth of material for you. I am seeing them come up more and more blogs and such. Brogan is Sayer Ji’s right-hand woman at greenmedinfo.com, for example.

        This is a good start, but there is so much more insolence to be distributed.

        http://sciblogs.co.nz/diplomaticimmunity/2013/08/20/dr-kelly-brogen-and-the-case-of-the-misplaced-science/

  16. Sastra says:

    One of the common claims I find particularly puzzling is the one which has pharmaceutical companies trying to suppress a simple, natural, ‘holistic’ cure for cancer (or cure for MS or arthritis or heart disease or what-have-you.) If said cure really worked, wouldn’t it be far more profitable for the Evil Pharma Conspiracy to get together and steal it? Claim it for their own? Patent it and regulate it and figure out how to market it so that people want it from them and only them ? I’d think the income from that would be enormous.

    The response I usually get is that “there’s no way to make money from it.”

    Oh please. There is ALWAYS a way to make money from something, particularly if it’s going to save lives and the customer knows it. It just seems downright perverse that the same group which apparently believes that Big Business and capitalism run the world and control everything also apparently believes that these same Overlords of Mind-control simply wouldn’t or couldn’t figure out a way to make a bundle by selling, making, developing, improving, or marketing some concoction of herbs and/or ‘energies.’

    1. David Gorski says:

      The response I usually get is that “there’s no way to make money from it.”

      I think that the immortal words of Stanislaw Burzynski’s lawyer Richard Jaffe come to mind here:

      A cancer clinic cannot survive on existing patients. It needs a constant flow of new patients. So in addition to getting the CAN-1 trial approved, we had to make sure Burzynski could treat new patients. Mindful that he would likely only get one chance to get them approved, Burzynski personally put together seventy-two protocols to treat every type of cancer the clinic had treated and everything Burzynski wanted to treat in the future…Miracle of miracles, all of Burzynski’s patients were now on FDA-approved clinical trials, and he would be able to treat almost any patient he would want to treat!

      There are always new patients with cancer, as it is a common disease of aging. It’s estimated that one in three people in the US will be diagnosed with cancer in his or her lifetime. Pharmaceutical companies could easily charge through the nose for the “cure” and just keep treating new patients as they are diagnosed. The supply, alas, is never-ending; so the profits could be potentially never-ending, at least for the time the drug could be on patent. Even after that, generics can make quite a bit of money, just not as much as drugs still under patent.

      I think that what might be going on behind this claim is the conflation of curing cancer with preventing cancer. The alt-med believers who make this claim seem to assume that a cure for cancer would also stop new cases from occurring, thus cutting off the supply of patients who would need the cure.

      1. MadisonMD says:

        One of the common claims I find particularly puzzling is the one which has pharmaceutical companies trying to suppress a simple, natural, ‘holistic’ cure for cancer (or cure for MS or arthritis or heart disease or what-have-you.)

        The hidden, ancient, or natural cure for [X] is, I submit, an archetypal myth.
        Examples:
        (1) Lorenzo’s oil
        (2) Solzhenitsyn’s novel ‘Cancer Ward’ (fungus cure becomes is all the rage among the patients while the doctors are using surgery, radiation, and vitamin C–the last for hopeless cases only).

        I even remember my 6th grade teacher telling us that the Library of Alexandria contained the cure for cancer but this was lost in the burning… he was serious. I find that one hard to substantiate.

        Burzynski and others appropriate the archetype to purvey their wares. Yet, the archetype itself is as old as the hills. It springs from deep within the human psyche and transcends cultures–why I find myself almost wanting to believe it. I suspect it will be with us, well until and unless we do cure all disease and our kids become immortal superbeings.

    2. One of the common claims I find particularly puzzling is the one which has pharmaceutical companies trying to suppress a simple, natural, ‘holistic’ cure for cancer (or cure for MS or arthritis or heart disease or what-have-you.) If said cure really worked, wouldn’t it be far more profitable for the Evil Pharma Conspiracy to get together and steal it? Claim it for their own? Patent it and regulate it and figure out how to market it so that people want it from them and only them ? I’d think the income from that would be enormous.

      This conspiracy theory just never made any sense to me. They make the claim that Big Pharma is so greedy to suppress cancer cures. But then, in the next breath, claim that Big Pharma isn’t greedy or intelligent enough to see the huge profits of a “cancer cure.”

      If Big Pharma uncovered some native root found in the jungles of the Amazon that reversed balding, cured cancer, grew back limbs, caused weight loss while eating 5 Big Macs a day, they’d be all over it, patenting it, determining the best dose response, the best delivery method, starting clinical trials, and getting regulatory approval. They wouldn’t hesitate. The shareholders would be happy. The Big Pharma execs would fire up their Cohibas, throw their feet up on the desk, and say “good day’s work.”

      The point is Big Pharma IS profit driven. And as such, they’re always looking for the next best thing.

    3. Bryan says:

      Also, what’s keeping North Korean or Cuban scientists from treating patients with this cancer cure that is so cunningly suppressed in capitalist states? In the Soviet Union, doctors and companies weren’t motivated by profit from 1917 until 1991. Yet, no cure for cancer emerged.

      It’s the light bulb conspiracy all over again. No communist country ever produced a light bulb that would burn forever.

    4. WilliamLawrenceUtridge says:

      Aspirin is off-patent and it (and its generic variants) costs pennies per pill, yet still companies manage to make a profit off of it.

      Even markets with the razorest of razor-thin profits still manage to have profits and stay in business. A cure for caner would be a huge money-maker over the short term, and most companies, even or particularly drug companies, only really care about the short term.

      A company that could make billions over the next ten years curing all existing cases of cancer with apple juice would happily do so even if it meant zero profits for its chemotherapy regimens ten years down the road. Ten years down the road means a new CEO, a new set of investors, and ten years of stock options, plus ten years worth of profitable medications going off-patent.

      Such a stupid argument.

  17. Jay Lee says:

    Of course, Trudeau isn’t a doctor. He is just a con man.

  18. Mark says:

    A 2012 study at Indiana University’s School of Public and Environmental Affairs demonstrated that 20 percent of “the one percent” are physicians. I saw a radiologist pay back all his student debt in his first year out of fellowship, and pocket enough to build one of the nicest houses in town. Age 31. If physicians aren’t motivated by money, then why are all these rules necessary???

    1. Harriet Hall says:

      1. You didn’t provide a link to that study, but I found it http://web.williams.edu/Economics/wp/BakijaColeHeimJobsIncomeGrowthTopEarners.pdf The details in the various tables are interesting to read.

      2. I can assure you the radiologist you mentioned is far from a representative example; he is the exception to the rule.

      3. “If physicians aren’t motivated by money…” Please read more carefully. I never said physicians weren’t motivated by money. I said they were not “only” out to make money. I insist that money is not the primary motivation of most physicians, even though we are just as capable as the next person of appreciating money when we can get it in the course of doing what is best for our patients. I never thought once about money when I made my career choice; in fact, my primary motivation was not exactly to help people either, but more like “Gee, this stuff is fascinating to learn about!” I was pleasantly surprised to discover that the occupation that interested me the most happened to be one that paid well. Going into medicine is not as good a way to get rich as going into some other careers (executive salaries are typically much higher), and the preparation for a career in medicine is far longer, more costly, and more onerous than most.

      4. I don’t know what you are referring to when you say “all these rules.” Perhaps you could elaborate.

    2. weing says:

      “A 2012 study at Indiana University’s School of Public and Environmental Affairs demonstrated that 20 percent of “the one percent” are physicians.”

      That’s outdated. Currently you have to be making around $400K to be in the one percent. About the only ones that make it there now are orthopedists.

    3. windriven says:

      Mark,
      It is perfectly reasonable to have a discussion about physician compensation – IF we’re going to move to a single payer system with physicians as salaried employees. In what passes for a free market system* many physicians operate as independent business people. On what basis do you claim influence over their earnings?

      Let’s say that the 20% of the 1% is true. I don’t know either way, but we’ll stipulate it for discussion purposes. These are people who have spent 23 to 30 years in school to attain basic competence in their chosen field. They are intimately connected to your health and well being. Your very life may turn on decisions they make. Somebody has to be 20% of the 1%. Do you think it would be more appropriate for that to be your stock broker? Lloyd Freaking Blankfein or another of his loathsome brethren? The guy that kicks field goals for your hometown football team?

      Don’t eat discount sushi and don’t choose your physician, attorney or accountant by their fee structure. Your life, freedom and solvency could depend on it.

      *There is very little about the American health care system that could lay claim to free market status. I use this as counterpoint to a single payer system.

      1. Andrey Pavlov says:

        *There is very little about the American health care system that could lay claim to free market status. I use this as counterpoint to a single payer system.

        There is very little about the US economy as a whole that is free market in the libertarian sense. The reality is that no such thing as a libertarian free market can ever truly exist – we need rules to regulate quality, protect consumers from shysters, and ensure safety. We also, rightfully IMHO, tend to go further and try and protect the environment too. The problem is that where our “free market” becomes patchy is exactly in ways to selectively benefit the rich. Romney saves insane amounts of money on taxes by donating an insane amount of his money… as “free” speaking fees. He “normally” charges $2-400k (yes, four hundred thousand) dollars to speak at an event. He will then waive entirely or reduce the charges and write off the amount as a charitable donation. How magnanimous.

        After the GFC it was noted that the economy did bounce back and people started making money again. However when you look at it, roughly 2/3 of ALL the increased money made was amongst the 1% and even worse their salaries increased on the order of 30-40% whereas the bottom 1% had theirs increase by 0.4%. Overall, since the early 90′s, the 1% has seen their income go up by close to 90%. And this is in a time when physician salaries have gone down or stayed flat, rarely going up (on average). So if we are 20% of the 1%, that means that 80% of the 1% snagged 2/3 of the new wealth in the US.

        1. windriven says:

          “The problem is that where our “free market” becomes patchy is exactly in ways to selectively benefit the rich.”

          Indeed. One of the tax laws that I will never understand is the capital gains rate for secondary stock transactions. The argument is that discounted capital gains rates spur investment. Horse hockey. When I buy a block of GE from Andrey, GE doesn’t get a penny. No jobs are created, no wealth is created. It is parimutuel betting. Discounting capital gains for direct investors does make sense. You want to see an explosion in entrepreneurialism? Do away with the capital gains benefit for all but direct investors. But Lloyd and Jamie would be aghast so … ain’t gonna happen.

          It is interesting to look at the history of incomes since 1970 and the ensuing creep in the GINI coefficient. It flabbergasts me that this isn’t a serious political hot potato. But I guess so long as Dick and Jane have cold beer and a big screen TV …

          1. Robert S. says:

            But GE gets a small mint of money when they issue stock. If “direct investors” can get the capital gains rate when they sell their share of the company, can the person they sold the share to do the same when they want to sell? If so, you have what we have now; If not, why would anyone buy stocks from the direct investor? If there are no buyers, the stock’s worth is zero.

            A problem is that only those with enough cash on hand can take today’s compensation as stock which is taxed at capital gains rates. I think an argument can be made that compensation in stock, when stock prices are decoupled from P:E ratios is the problem.

            1. windriven says:

              “But GE gets a small mint of money when they issue stock. If “direct investors” can get the capital gains rate when they sell their share of the company, can the person they sold the share to do the same when they want to sell? If”

              Yipes. Typo. Should have been small amount of money.

              No, that is precisely the situation we have now. The first or direct investor’s investment can be seen to fund new jobs, capital equipment, and research. That is a potential benefit to the larger economy and that, arguably, deserves preferential tax treatment when the stock is sold.

              Later purchasers are buying either on the hope of dividends higher than those available from deposit accounts or as a form of parimutuel betting. There is no greater social good attached to these transactions and no reason that profits should not be treated as ordinary income.

              “[W]hy would anyone buy stocks from the direct investor?

              For all the reasons they buy from direct investors now: dividends or capital appreciation – just without the preferential tax treatment. Why should the capital gains of a stock speculator be taxed at half the rate of the earnings of a physician or an engineer?

              “when stock prices are decoupled from P:E ratios is the problem.”

              And don’t you think that subsidized speculation encourages that decoupling? The market would become much less volatile if stocks were judged primarily on their ability to deliver dividends. It would have an added benefit of encouraging a longer term outlook from management.

              1. Robert S. says:

                Nope, a small mint is what I meant. I was referring to the place where coins are struck and paper currency is printed. I think the last offering by the GE family of companies was something on the order of 5 billion dollars worth of stock.

                Another possible gain to an investor is if the company has a buyback of stock. Stock is not just an agreement to be paid dividends off of future profits, but a fractional ownership of the company itself. The worth of the company is how much 100% ownership would cost, which is to say, how much it would cost to own all of the stock. The benefit to society is that it’s companies (capital) are by definition worth more when stock prices are higher.

          2. windriven says:

            @Robert S

            Okay. And what does any of that have to do with preferential taxation?

            I was especially confused by this:

            “The benefit to society is that it’s companies (capital) are by definition worth more when stock prices are higher.”

            I don’t understand the ‘benefit to society’ part. GE, to stay with our example, has a market cap of $278 billion. So what? Unless you own GE shares, what is the difference if the market cap is $300 billion or $1.22?

            I bought GE at around $7 a couple of years ago at the bottom of the market and sold it later at $26. Did the inherent value of GE almost quadruple during that period? No. Is there any good reason that I paid capital gains rates for that investment rather than regular income tax? No. The $7 didn’t benefit anybody except the party that I bought from and the brokers involved. The $26 didn’t benefit anybody except me and the brokers involved. No part of either transaction had any impact on the competitive fitness of GE.

    4. David Gorski says:

      A 2012 study at Indiana University’s School of Public and Environmental Affairs demonstrated that 20 percent of “the one percent” are physicians. I saw a radiologist pay back all his student debt in his first year out of fellowship, and pocket enough to build one of the nicest houses in town. Age 31. If physicians aren’t motivated by money, then why are all these rules necessary???

      If you want to argue anecdotes, I’ll tell you mine. I didn’t get my first real job until I was 37 because I spent so much time in training. Up until that time I was either in college, medical school, or poorly paid residency and fellowship programs. Then, I didn’t manage to pay off my student loans until I was well into my 40s. Now I’m in my early 50s and it’s only now that I’m starting to feel financially secure. With retirement between 15 and 20 years away (hopefully, but in today’s economy, who knows) I now have to save relentlessly.

      Don’t get me wrong. I’m not claiming that I’m poor, or even middle class, but I was at best middle class for many years, and it’s only in the last few years that I’m starting to feel moderately affluent. True, I could have done better financially if I hadn’t gone into academics, taken time to get a PhD, and done a fellowship, but that’s the way it is.

      1. goodnightirene says:

        And you didn’t even have kids, which would have slowed your rise to affluence even more. :-)

        1. Andrey Pavlov says:

          Thankfully my better half is in full agreement that definitely no kids in the near future and possibly no kids at all. The latter is unlikely, but it won’t be until our mid-to-late 30′s at the earliest for us.

  19. Teachers are right up there with you doctors for being on the whipping post. I never made much, but I loved my job so much that, after teaching for almost 40 years, I retired from the classroom and have been teaching online every since–at the age of 72. I keep in touch with my past students via Facebook. What I did/do had value, but it was not in the money I made. My top earnings for a year: $30,000. (remember–40 years?) it was still worth it.

    1. Andrey Pavlov says:

      Agreed. And thank you for your service as a teacher. Truly one of the most important professions we have.

      1. Dave says:

        I’ll second that comment. Our future depends on teachers.

    2. Chris says:

      Yay, yay!

      In a couple of years my younger son will hopefully become one of the more beloved types of teachers (swimming), to one of the more hated: high school math.

      By the way, these days teachers now need a Master’s degree to get a job. Even more reason to respect them. My son must volunteer at a school before he applies to an education graduate program.

  20. Lucas Beauchamp says:

    “Don’t do imaging for low back pain within the first six weeks, unless red flags are present.”

    Evidently the chiroquackter whom I went to fifteen years ago had not heard this. I woke up one morning with back pain, and he immediately took X-rays. After carefully perusing the pictures, he diagnosed me with . . . a subluxation.

    That was before I knew what chiropractic was. I quit going when his colleague tried to sell me a supplement.

  21. Dave says:

    I’m currently a salaried hospitalist, which I find far preferable to when I worked untold hours in private practice for considerably less reimbursement, but I would like to relay a scene I witnessed in a hospital at 3 am one morning. Dr C, an infectious disease specialist, had been up all night in the ICU with a patient he had been asked to see who was in septic shock. He had worked all the previous day and had a full day ahead of him, and he groused to the ICU nurse abut how tired he was. The ICU nurse responded, “Yeah, but I wish I was making what you are”. His reponse was that if that was true she should tell her supervisor that she should not be paid for that shift, because the patient he was seeing was indigent, had no insurance, and Dr C was not going to make a penny for his night of work.

    This scenario actually plays out frequently. It ihas changed a little over the last decade with the advent of salaried hospitalists like myself, but generally doctors would take service call and do what Dr C was doing on a regular basis. I never saw these patients get less care from the doctors involved than other patients. In the hospitals I have been associated with such patients comprise about 15-18% of the population. This means in economic terms that about one day a week of hospital work was done unreimbursed. You can say the cost was shifted by the hospitalsomehow, but what Dr C was doing was for “free”. His income was not going to be higher for his night’s work, or for the work he put into the patient for the next week.

    We also saw medicaid patients. The logistics of this was worked out by one of the family doctors in the area. He calculated that the reimbusement was such that accounting for his overhead, he had to pay 5 dollars out of pocket to see a medicaid patient. Some doctors have quit seeing these patient for this reason. Those who continue to do so are NOT doing it for the money. Medicare reimbursements are unfortunately getting to be the sme way. Those readers out there who are on medicare – your doctor is not seeing you because of the reimbursement. He or she would be much better off economically to use that time slot for another patient.

    Some years ago there was a terrible push to start referring to patients as clients. In my life I’ve dragged myself out of bed numerous times to go into the hospital to see a “patient”. No amount of money could have made me do that for a “client”. Ditto for all the other doctors who did the same thing.

    There are other professions where such service is done. Some lawyers do pro bono work, for example. I’ve not seen other professions do it to the extent Medicine has.

  22. Ward says:

    The conversation reminds me of a story I read thirty years ago when I was seeing some of the first HIV infections.

    There is a cancer that is an AIDS defining condition, called Kaposi’s Sarcoma. Moriz Kaposi was a dermatologist who described the condition in the late 1800s. He married the daughter of the chairman of the department of dermatology. For a wedding present, Dr. Kaposi’s father-in-law transferred the care of six wealthy patients who had severe psoriasis. Thus the father insured the well being of his daughter for the duration. I’ve never seen the like of it but gifting wealthy patients with chronic incurable illnesses to your son in law doctor must be rare indeed, if not amusing.

    http://www.jbuon.com/pdfs/1101-1105.pdf

  23. stanmrak says:

    This is an argument that really benefits the pharmaceutical industry, the health insurance industry and the healthcare system at the corporate level, as it diverts the attention off of them. These are the guys who are greedy, power-hungry, and don’t care about the patient, only the bottom line. The doctors are just pawns. Most of them are genuinely ethical and compassionate, but they only know what their masters want them to know.

    1. Chris says:

      So we should just listen to random people on the internets and buy their supplements? Is that right, Stan?

      So what kind of training do you need to be a Antiaging Nutrition and Disease Prevention Expert? So does that require a college degree, or just reading some books in the self-help section of the bookstore?

      1. stanmrak says:

        The curriculum at most nutrition schools is controlled by corporations who donate money to the schools and dictate what is taught. Today’s licensed nutritionists are brainwashed with corporate propaganda.
        To find the truth, you have to educate yourself. Apparently, you haven’t discovered that. Alleging that everything on the internet is BS is the mantra of those who want to suppress the truth, and you have fallen for it.

        1. BillyJoe says:

          Ah, a degree for the university of google!

        2. MadisonMD says:

          Alleging that everything on the internet is BS is the mantra of those who want to suppress the truth

          You’re right. We would not want to say everything on the internet is BS when you can find the truths in Pubmed, Quackwatch, and SBM on the internet.

          And who is ridiculous enough to choose to meditate to a mantra that is in of itself an allegation? Is this what a DA guru does? Such a legal swami is no better than this!

        3. Chris says:

          You did not answer my question. Let me try again:

          So what kind of training do you need to be a Antiaging Nutrition and Disease Prevention Expert?

          Did you not understand the question? List the curriculum, and example texts. Tell us where you find your form of valid information.

          1. stanmrak says:

            I get my information from people who have spent their entire lives studying and practicing nutrition and disease prevention, not amateurs trained in something else who think that peer-reviewed scientific studies hold all the definitive answers.

            1. weing says:

              “I get my information from people who have spent their entire lives studying and practicing nutrition and disease prevention, not amateurs trained in something else who think that peer-reviewed scientific studies hold all the definitive answers.”

              And they did all this without using peer-reviewed scientific studies? And if they did scientific studies you wouldn’t believe them. That makes sense. Faith and belief are for the category of things that are not true. You believe it because it is not true.

              1. stanmrak says:

                By “amateurs”, I’m referring to people who know very little about nutrition, but they read a few published studies and think they know something. People I listen to have studied published research as well as using their own independent findings and those of other experts who have likewise spent their lives studying nutrition — not drug and surgery-based medicine. Stick to what you know.

              2. Chris says:

                So what are your credentials, Stan?

                Give us the total synopsis of your training. Stop evading the question.

              3. MadisonMD says:

                People I listen to have studied published research

                So, please provide citations to the published research and then we will learn.

            2. Chris says:

              Still not an answer. There are plenty of online dictionaries to tell you what “curriculum” means.

              So who authored those texts, and where did they get their training. What is their (and your) background in basic biology and science?

              For someone who claims to be an expert you are very dodgy about your education.

        4. WilliamLawrenceUtridge says:

          The curriculum at most nutrition schools is controlled by corporations who donate money to the schools and dictate what is taught

          That’s rather rich given the consistent advice is “get your nutrients from foods, not vitamins; eat fresh fruits and vegetables; prepare your own food; control portion size; get adequate exercise”. Who controls nutrition schools, Chiquita?

    2. MadisonMD says:

      but they only know what their masters want them to know

      What, precisely don’t doctors know, Stan? (Besides your idea that people should take more supplement pills– see I don’t like asking people to take more pills, Stan.) If you’d enlighten us with factual evidence supported by data– well then we’ll know it.

      Please no BS.

      1. windriven says:

        stan – BS = empty set

      2. stanmrak says:

        Primarily, doctors rely on the data, reports and peer-reviewed research they read in the journals to be factual and scientific. Well, often they’re not. The journals have been taken over by the pharmaceutical industry and turned into another marketing tool.
        I suggest you get the book by former editor of The New England Journal of Medicine, Dr. Marcia Angell if you doubt this.

        http://www.amazon.com/exec/obidos/ASIN/0375508465/optimalwellnessc

        Synopsis: During her two decades at The New England Journal of Medicine, Dr. Marcia Angell had a front-row seat on the appalling spectacle of the pharmaceutical industry. She watched drug companies stray from their original mission of discovering and manufacturing useful drugs and instead become vast marketing machines with unprecedented control over their own fortunes. She saw them gain nearly limitless influence over medical research, education, and how doctors do their jobs.

        I feel sorry for doctors who are being manipulated by these people, not to mention their patients.

        1. MadisonMD says:

          Thanks, Stan. I am sure Marcia has many important insights and I myself am well aware of the attempts of pharma companies to persuade MDs to sell there wares. I am quite wary of their practices, and fortunately I have seen big improvements in the past decade, but there are still issues.

          Now, I’m really hoping you can tell me something I don’t know. You said:

          [Doctors] only know what their masters want them to know.

          and then you said:

          The journals have been taken over by the pharmaceutical industry and turned into another marketing tool.

          So I am extremely puzzled that you then tell me to read a book about a doctor who was an editor of the premiere medical journal. This seems to directly contradict what you said. It seems that if your assertions are correct, then this doctor shouldn’t know it and she should be paid well by industry not to write this book. (Also odd is the 5-star rating by somebody who claims to be a pharma marketing exec as the first review on Amazon.com– but thanks for sending the link).

          Anyway, could you just tell me one specific thing I don’t know? Once you tell me what it is, then you can point out a book or (better yet) a citation to back it up with data.

          1. stanmrak says:

            As the EDITOR, Engell was able to see the deception from the inside. The fact that she’s a doctor is irrelevant to the point. In this case, her role is as a whistleblower.
            Most doctors get their “continuing education” from what they presume to be reliable sources, like JAMA or NEJM or the drug companies. They don’t have any idea how much of the information they get is biased, manipulated science or downright fraudulent – unless they are on the inside, like Dr. Angell. Many of the studies that come out with unfavorable conclusions (for the drug company) never see the light of day. Look at history if you doubt any of this.

            1. Sawyer says:

              You did not even come close answer the question. When Madison asked for a book, you don’t get to throw out a book that is tangentially related to the subject. Do you understand the concept of providing references, or even answering questions?

              I really, REALLY want to discover the secret list of poor arguing techniques that must be circulating around the alternative medicine community.

              “Someone mentions drug companies? Throw out a reference to one of these four books written by somewhat respectable authors about drug companies without actually answering anything. Continuously point to the credentials of the author and insist their viewpoint is the divine truth – except the author’s criticisms of your own brand of quackery, which you can conveniently ignore.”

              Is this a bullet point in a list somewhere? I’ve seen A LOT of people employ this argument and they all think it works. It doesn’t.

            2. Dave says:

              I think most doctors are very familiar with Dr Angell and her views, which were sometimes expressed in editorials in the NEJM. I had a previous post about numerous studies that have been reported which have decreased the usage of drugs by physicians or the recent study in the NEJM looking at knee surgery. You choose to ignore these studies, of which there are many.

              This is a quote from the Sept 15 2013 issue of the American Family Physician, in an article highlighting the top 20 research articles of 2012:
              “Whether we are talking about control of blood glucose levels, cardiovascular prevention, or the interval for osteoporosis screening, sometimes less testing or less treatment can be better for our patients. It is worth examining the Choose Wisely campaign, which provides a long list of evidence-based recommendations for more efficient care”

            3. MadisonMD says:

              Stan,
              Your response is bizarre.

              First you tell us that doctors don’t know what companies don’t want us to know. To substantiate this, you cite a doctor, invalidating the very idea. Now you tell us to ignore that she is a doctor, but recall that she was the editor of the NEJM– where she regularly wrote editorials in the journal most widely read by doctors. Now that’s one hell of a way to keep secrets from doctors.

              You said:

              [Doctors] only know what their masters want them to know.

              I have asked you twice to Tell me one specific thing I don’t know, You have twice avoided answering this question.

              Shall I conclude you don’t have an answer?

              1. Chris says:

                For a guy who claims to be an expert and have all the answers, Stan seem very evasive recently. Do you think he has something to hide? Like a whole lot of of nothing? I suspect if you took his actual knowledge and threw all in a sealed box you would have a perfect vacuum.

                I think I will be asking him the following question now each time he posts here: “So what kind of training do you need to be an Antiaging Nutrition and Disease Prevention Expert ?”

                I am very curious about the “disease prevention” bit. Which a bit of selective googling on this site, I quickly found this glorious quote from him: We object to forced vaccinations because vaccines are not thoroughly tested for safety, and never have been. Any honest vaccine researcher will admit that the evidence for LONG-TERM safety just isn’t as substantial as they would like you to believe. 10-day studies just don’t cut it.

                I wonder what his ideas are to prevent measles, pertussis and haemophilus influenzae type b. Should babies be given the multitude of supplements he shills?

        2. WilliamLawrenceUtridge says:

          Wouldn’t the solution to the problem of the pernicious influence of Big Pharma on research and marketing be greater control over that marketing as well as an alternative form of funding and drug approval? In the past I have suggested that in order for a drug to be licensed in the US, the drug company would have to hand the cost of testing over to the FDA for third-party testing. I think it’s a good solution. You should talk to your congressperson about it.

          I’m not sure how the proper solution can, or will ever be, “abandon all science and instead trust supplement manufacturers who have even fewer controls over their products than Pfizer”.

  24. AHodges says:

    The irony of this is that alt med manufacturers/providers really do make a living off of unnecessary treatments and “medications.” Between chiropractors and acupuncturists with their vague, open ended treatment plans, and expensive homeopathic products that are little more than water or sugar, the alt med industry is really cleaning up.

    It’s too bad that I have this pesky ‘ol conscience, without it I could join the quacks and make a fortune.

    1. Chris says:

      You do not know how many times I have told to get my kid who has had seizures and a severe speech disability “cranial sacral therapy.”

      It is a form of “chiropractic neurology.” It is essentially a homeopathic head massage that they claim reorganizes the energy in the brain. I often reply that their energy will not penetrate down to either Broca’s or Wernicke’s areas of the brain and repair damage from the spurious electrical chaos that caused my kid to lose consciousness after convulsions when he was a toddler suffering from a now vaccine preventable disease. I usually do not get a reply back.

      1. AlisonM says:

        Ugh. I know what you mean. I’m dealing with someone on a support forum who insists that ADHD and ASD (among other things) are caused by “Atlas subluxation” brought on by “Upper Cervical Birth Trauma.” This would mean that pretty much everyone who was born through vaginal delivery would have some sort of neurodevelopmental disorder. . .and need lifelong adjustments to “cure” it.

        Pointing out that the rate of neurodevelopmental disorders is nowhere close to 100% among all people delivered vaginally, or that this person’s decades-long chiropractic treatment has done nothing to ease his own symptoms results in the same type of response.

    2. Greg says:

      Perhaps the problem with woo is more insidious than you think, in that many millions of people ascribe to faith-based religion and within that religion they are indoctrinated to believe in miracles. Sets the table perfectly for all the con-artists and their miracle cures – if it sounds really great and plausible then people believe it, much as they believe religious leaders.

  25. sett says:

    Could you write an article about clinical trials in oncology? Some of the trials are obvious failure and damage for the patient, still doctors recruit from 80 to 120 people for it. How does that work with them being nice and not going for the cash?

    1. weing says:

      “Some of the trials are obvious failure and damage for the patient, still doctors recruit from 80 to 120 people for it.”
      And you know this prior to the trials? How?

    2. MadisonMD says:

      Hi sett,
      Some trials are also successful– leading to several examples of new drugs being approved for standard treatments. See the list of 2013 FDA-approved hematology-oncology drugs.

      If we knew the what the results of a trial were going to be, there would be no need for the trial. A failed phase III clinical trial–which you allude to– costs the sponsor of the trial millions of dollars with not a dollar to be earned. Why would a sponsor run a trial that they know would be unsuccessful?

      Most of these new drugs are being developed to replace chemotherapy, and to either cure more cancers or to make treatments more effective and less toxic. How do you propose to make treatments better in the future without clinical trials?

      Incidentally, you seem ill informed about finances (usually doctors lose money by participating in a clinical trial) and statistical design of clinical trials (drugs that lack promise are killed before phase III trials of the size you specify–if they are not, then a great deal of money is lost).

  26. Kelsey says:

    I’m new here; hopefully this doesn’t get lost in the sea of comments.

    My own impression of doctors is that they are generally trustworthy, and while there are a few bad apples, most are not just out to strike it rich. But I would submit that the bad apples are likely to be concentrated in particular specialities, namely, those who make their living on procedures that are entirely elective– things like cosmetic surgery, abortion, and yes, alternative medicine. I see a greater conflict of interest in those areas, because they have to actively court already healthy people to be their customers. Whereas when a doctor is treating an illness, the patient’s interest in health and the doctor’s need to get paid line up.

    Any comments/critiques?

    1. Andrey Pavlov says:

      @kelsey:

      Hello and welcome!

      I think your question is a bit tough to answer. There is probably at least some truth to the idea that certain specialties may attract the “bad apples” of medicine more than others. However, the arrow of causality is not certain and I would argue is more about a self selection bias. It isn’t that bad apples make the specialty – every single specialty has vastly more genuinely good physicians than not. This is because there are simply vastly more genuinely good physicians than not. But, if you happen to be one motivated by money and avarice with little consideration for patients then you would likely gravitate towards a specialty that lends itself to allowing you to continue acting and behaving as you otherwise would.

      That said, it becomes significantly much more confounding than that. In all cases there are examples of the exact same practice being good or bad depending on context and your particular definition of good or bad. My Aunt, for example, is a concierge cosmetic dermatologist in a major metropolitan area and has many clients who are on Forbe’s Fortune 500 list. Does that make her a “bad apple?” No – she genuinely cares about her patients, works hard, and offers a service that people are willing to pay for. She has cultivated a patient base that is indeed already healthy and sells them things that they technically do not need. However, this is not intrinsically unethical and one must also recognize that she actually does spot cancers and treats them as well, along with other difficult skin conditions.

      This also translates into the “bad apple” physician – (s)he will inevitably do some significant amount of good regardless of how much avarice they end up harboring and trying to exercise. Additionally, pretty much every single plastic surgeon I have ever met (with the exception of one who truly was a “bad apple” in my book) holds both an elective practice and a reconstructive practice. It is not only financially better to include elective procedures personally, but also allows you to do better for your non-elective work since you get more practice under controlled conditions to better your technique, knowledge, and skills. Also all save that 1 do at least some pro bono work for special populations. Sure, some are 100% purely elective but once again I don’t know that I would call that a “bad apple.”

      Another confounder is that those specialties that one may think aggregates “bad apples” tend to also be the more competitive and difficult to get into. The “good apples” tend to want to be in the field for the same reasons – better lifestyle, more pay – and others such as genuine interest. So you may be a “bad apple” who just isn’t smart enough or doesn’t work hard enough to actually get into said specialty and end up in a different one you may not have otherwise expected to attract “bad apples.”

      Lastly, and to tie in with everything else, all fields and specialties have some utility to them. Even abortions. There are many medically and psychiatrically sound reasons to perform an abortion. And particularly with the heated debates and, particularly in the US, history of outright gunning down of physicians who perform abortions I would argue that particular field is likely to have a much lower prevalence of “bad apples” than most others. Someone who is only in it for the greed will be dissuaded because of how much sociopolitical turmoil they tend to face in that field.

      So I think the issue is significantly more complicated and it is nearly impossible to make any sort of generalizations about specific fields or practices that may or may not be particularly populated with “bad apples.”

      1. Kelsey says:

        Thanks for the welcome– and just to be clear, I didn’t mean to insult your aunt!

        Happy new year :-)

        1. Andrey Pavlov says:

          Hi Kelsey.

          I did not take any insult at all! I was just using a convenient example to illustrate the larger point.

          Hopefully you found it (the post overall) useful.

          Happy New Year to you as well.

      2. goodnightirene says:

        Your Auntie is the kind of dermatologist I run from–I don’t buy your justification for her non-medical “sidelines”.

        1. Andrey Pavlov says:

          @goodnightirene:

          Also not the physician I wish to be. The concierge medicine debate has been going on and, IMHO, there are valid opinions to be had on both sides. Ultimately I feel that she – and those like her – still do quite a bit of good, definitely have a niche practice wherein the patients know what sort of relationship they are entering, and ultimately in this case I feel that personal freedom (to be a concierge doctor) outweighs any sort of remaining negatives left over. In fact, whilst I would not become a concierge physician for my entire career, I may find it worthwhile to become one as a semi-retirement later on and cater to just a few clients by offering top notch 100% science based and effective medicine. I’d also love to be a professor of medicine and the two are not mutually exclusive.

          Of course, I can also 100% understand and quite frankly agree with not having a desire to personally visit a concierge physician. But I also don’t see a need to buy $10,000 shoes or $500 flip flops, yet I am not agitating for their banning. The population that can and will do such things is not the population that terribly needs much protection from getting swindled out of a few extra bucks (not to say that my aunt is swindling them, but even in the worst case I still wouldn’t be concerned) and they, quite frankly, enjoy overspending for what they at least perceive is “the best.”

          1. mousethatroared says:

            Whether some specialties have a larger percentage of bad apples or not is an empirical question. One could collect data…or I suppose one could reference something like BBB complaints (for procedures not covered by insurance or Medicare) or Medicaid scams. I’d hate to speculate.

            I’d agree with AP on doctor’s who do elective procedures. Many plastic surgeons that do cosmetic work also do brilliant reconstructive work too and volunteer.

            Personally I can see a need for doctors who do cosmetic dermatology. When I was having problems with the redness/puffiness around my eyes, the dermatologist and rheumatologist didn’t focus on resolving that symptom because it was cosmetic. Fair enough, it wasn’t an infection risk and it didn’t cause much discomfort or any vision problems. But to me, it looked bad. If there are possible safe and effective treatments, I think it’s okay to work with the patient to find those treatments at the patient’s expense.

            Also, a cosmetic dermatologist helped my sister who has problems with eczema/dermatitis find a make-up that she can wear on special occasions. That’s not a medical necessity but there’s nothing wrong with it, that I can see.

            On the other hand, would I approach a cosmetic dermatologist who pushing a line of miracle wrinkle creams with caution? Yes, yes I would.

  27. Barbara says:

    Most people work to earn money. Professionals take on the job because they have a passion for it and a desire to help others. The cost of running a professional office is phenomenal and continues to increase every year. It is even more of a challenge when people accuse you of solely being out to make money. Everyone needs it to pay their bills, so it is a ridiculous statement.

  28. Mojo says:

    I’m sick and tired of all the doctor-bashing. They accuse us of being shills for Big Pharma. They say “Doctors are only out to make money.” Or “Doctors are greedy bastards only interested in the bottom line.” Or as one of our commenters recently put it: “First do no harm. Second ? Third, profit [sic]”

    I would just ike to point out that I was commenting on the habit that proponents of sCAM have of parroting “first, do no harm” as if that’s all that matters (and that this usually comes from those such as homoeopaths who have nothing else to offer). The part of my post that was inside the blockquote tags was a quotation from the letter Mark Crislip quoted in his blog post, and that is what I was commenting on. I was not commenting about doctors. My subsequent comment on that page should have made this clear, but perhaps I was still being too elliptical.

    1. Harriet Hall says:

      I used it as a convenient shorthand for a common attitude. No reflection on your personal opinions.

  29. Ramon Casha says:

    I totally agree with this article. At the same time there are a few practices that, IMO, cast a pall over medical practice, and should be discontinued. One of these is the practice of several pharma companies to pay a commission to doctors to prescribe their products. This is a temptation for doctors to prescribe more than they have to, or to go for a more expensive product – and some doctors do both unfortunately. Recently, GSK made the news by announcing it would not do this any more. This should be the rule not the exception. Doctors should recommend generic products and not brands, and there should be no incentive to prescribe a specific product other than it being the right product for the patient.

  30. Thright says:

    I agree, there are many doctors who do not think about the money. I have even met some doctors who never took any fees and they are in villages.

  31. Morgan says:

    “…it reinforces a common misconception that doctors care more about their own income than about their patient’s outcome. That accusation is demonstrably untrue.”

    Can you give me a randomized double blind study on that “demonstrably untrue” data?

    Frustrating isn’t it, if you have first hand empirical data, but it’s not the kind of data your audience wants?

    1. Sawyer says:

      Morgan I think you’ve inadvertently highlighted a dilemma in modern medicine, but it’s not the one you’re trying to make. How would you even do an RCT on this question? What is the controlled, double-blinded experiment that would be performed? The only way to test this claim would be to develop a healthcare system from scratch where physician compensation is completely independent of their behavior. This would be necessary in order to eliminate any confounding factors. No person on Earth would think this system was ethical or fair, and it would undoubtedly foster a tremendous number of quack therapies.

      We have to rely on “natural experiments” to see how often doctors do things that benefit their patients with no additional financial gain. Take cancer screening for example. David Gorski, the resident oncologist at SBM, has written several times about overly aggressive screening for prostate cancer having very little effect at reducing mortality. Despite the financial benefit for doctors, Dr. Gorski (and I assume Dr. Hall) would be perfectly fine with cutting back on these tests. Their recommendations result in less money funneling into the pockets of doctors and drug companies. Admittedly not all doctors have these same standards, but pretty much everyone reading this site is on board.

      There are countless other examples if you have the patience to look for them. But as a word of advice, it’s not a good idea to bump old article unless you have relevant expertise on the subject.

    2. Harriet Hall says:

      My article demonstrates that the medical profession as a whole does many things in the interests of patient outcomes that tend to decrease their income. I also pointed out that a large percentage of doctors work on a straight salary basis, so no changes that they make in their practice have any effect on their income. No, I can’t cite an RCT. There are a lot of things that are demonstrably untrue that are not supported by RCTs; there are other kinds of evidence. We don’t need an RCT to know it is untrue that breatharians can live without food (imagine trying to get IRB approval for an RCT to test that!). The actions of the medical profession as a whole, in consistently discontinuing lucrative but unnecessary tests and ineffective treatments, speaks louder than the actions of a few unscrupulous individuals.

      1. @hall “There are a lot of things that are demonstrably untrue that are not supported by RCTs; there are other kinds of evidence.” We don’t need an RCT to know it is untrue that breatharians can live without food (imagine trying to get IRB approval for an RCT to test that!).

        Did this come out of your finger tips? Now does this jive with Acupuncture?

        “The actions of the medical profession as a whole, in consistently discontinuing lucrative but unnecessary tests and ineffective treatments”

        From my view this is not the case, the business of medicine is always on the move to circumvent or benefit from the system and make money off of the sickness and infirm.

        1. MadisonMD says:

          Now does this jive with Acupuncture?

          Coherence, Stephen. It is the concept that a given hypothesis does not exist in isolation but should be consistent with generally known facts. It is one of Hill’s criteria of cause and effect.

          The reason you don’t need a RCT for to know that breatharianism is a plain falsehood is simple. It is well known that people starve without food and, moreover it undercuts the basic physics of conservation of energy.

          Admittedly, acupuncture is not as implausible as breatharianism. However, it does posit specific points on the body that elicit effects in distant organs based on an undetectable energy flowing through tubes which are anatomically non-existent. We don’t need nor want a RCT to accept or reject it. A well-established biological/physiologic construct would be the main acceptable starting point.

          Your flavor of acupuncture seems more like trigger-point needling of muscles. Again, this is not implausible and does not conflict greatly with basic physical facts (although it does imply new concepts in physiology and anatomy). What trigger point injections lack is basic objective evidence about what trigger points are, how they can be objectively located, the pathophysiology, and the mechanism by which disturbing them with needles would be therapeutic. If the basic evidence was in hand and capped by RCT, this could establish it as a useful therapeutic.

          A critical issue covered here repeatedly is that an RCT alone cannot be definitive. Testing implausible treatments with RCT in the absence of coherence will lead to many false therapies believed to be “proven” effective. This is an unavoidable fact based on statistical design of RCTs.

          So, coherence and basic research is sufficient to rule out and reject a hypothesis. However, to rule a hypothesis in and accept it as effective, will generally require RCT as the last step of proof. There are rare exceptions to the need for RCT to rule in, such as when uncontrolled effects are sufficiently remarkable given prior experience, and is coherent with basic knowledge, the intervention is accepted as standard without RCT (e.g. imatinib, penicillin, or of course the mundane and obvious example of a parachute).

        2. WilliamLawrenceUtridge says:

          Your comment about breatharianism tailors quite nicely to this site’s mandate – when basic science informs a topic, you don’t need to spend much time or money determining if it’s true. Of course, that’s why acupuncture gets such short shrift, and that’s why the contributors are so annoyed that it, along with all other CAM scams, gets any respect.

          Now does this jive with Acupuncture?

          Easily. The results of acupuncture testing show that none of the aspects of the intervention actually matter except the confidence of the practitioner and whether the person getting needled actually believes they are getting “real” acupuncture. Thus, acupuncture is well within the bounds of what we know about the placebo effect. 3,000 clinical trials were not necessary to find out that pain and nausea are susceptible to placebo interventions, and acupuncture is one of them.

          From my view this is not the case, the business of medicine is always on the move to circumvent or benefit from the system and make money off of the sickness and infirm.

          And that’s why you are seen as a condescending asshole, because you are basically saying “I am in it for my patients, but everyone else is willing to harm their patients out of pure greed”. What a shitty thing to say, and how blind it is to the realities of medical care in the United States, with its highly litigious nature, the lack of a public health care option, the nature of defensive medicine, the demands of patients for certainty and testing, the increasing power of patients in making decisions without doctors being paid for the time it takes to inform them of the consequences of the decisions, and more.

          You’re taking a complicated series of interacting problems and turning it into a simple story about how an entire profession (except you!) is actively attempting to hurt the group it is supposed to help.

          You’re not a saint Steve, you’re trying to justify your decisions in the face of consistent criticisms that you can’t respond to rationally.

  32. Right. And quacks like homeopathists are not out to make money? Next time you get the bill from one, just tinker with a couple of dimes in your pocket. Since the high dilution of money will make it even more potent, he will be happy that you overpaid him several times. Oh, sorry, he insists on payment with hard cash? Maybe he’s in it for the money, after all…

  33. Braindead says:

    Sure are a lot of jackass liberal apologists in here. Making excuses for wealthy doctors who are in it for the money. Try working a blue collar slave job and try to survive. You will pay 20% of your income for health insurance, which wont help pay your bills until after you pay thousands in deductibles which you of course can’t afford to pay. Meanwhile you work second jobs serving the wealthy.

    1. WilliamLawrenceUtridge says:

      Braindead:

      Consider what would happen to the medical system if doctors required the training they currently do, but were paid blue-collar wages. I daresay you would have considerably more doctors.

      If you have issues with the wages of blue collar jobs, then getting mad at doctors won’t help. Doctors don’t set wages, they try to cure your cancer. Blue collar jobs are generally poorly paid due to a near-infinite amount of replaceable workers, many of whom are willing to do the same work for less (also feeding into it is the fact that in wealthier countries, the use of capital allows greater productivity per worker while increasing the level of education and training required on a per-worker basis; basically one engineer can replace dozens of workers, even though the overall cost is more for that engineer). It’s not liberal apologist jackasses who prop up this system, by the way. Liberals generally tend to support unionization and basic income supplements. It’s generally jackass conservatives and the rich industrial lobbyists who fund their campaigns that tend to remove worker protection legislation, minimum wage increases and things like reduced capital gains taxes that reduce government revenues.

      This brings up an amusing point. Doctors are apparently “in it for the money”. Does that mean blue collar workers do it for the job satisfaction?

      I agree that the cost of health insurance is prohibitive and stupid. A federally-funded health care system would be much, much more sensible, but the championing of such a system by liberal apologist jackasses is generally opposed by the greedy, wealthy libertarians and conservatives whom you seem oddly unwilling to blame.

      This comment brought to you by a liberal apologist jackass who went to school, ended up with a lot of student debt, which he paid off over more than a decade, who actively supports a living wage for blue collar workers, their ability to unionize, and a national health care system for all countries, particularly the US.

      Also, you should seriously think about some sort of activism to oppose redistricting, the absurd gaming of your political system basically to serve Republican ends.

      1. weing says:

        @WLU,
        I disagree about raising the minimum wage. I just don’t see how it improves anything as prices just increase commensurately and it becomes a case of a dog chasing its own tail. I’m all for decreasing inequality by capping the maximum wage.

        1. Increasing the minimum wage would allow people to be more independence and not have to rely on food stamps, medicaid and social services have more purchasing power, invest more, spend more and feel more secure about their future.

          It would flood the middle and bottom with capital, shaving it off of the upper middle and top. Those folks can not spend, purchase or be taxed enough to fill the void.

        2. Andrey Pavlov says:

          I am well outside my depth of expertise on this one, but my understanding is that this is true only beyond a certain point. As of right now it isn’t so much that the raising of minimum wage is inherently and always a benefit, but that the minimum wage is so low as to be creating a system of indentured servitude with government subsidy to facilitate the current minimum wage. I’ve read a couple of analyses on it and they seem to find consistently that the curves intersect at around $15-18/hour. Which is, as it happens, right where the Australian minimum wage is set. They are definitely much more expensive and have a very high cost of living, but for people within Australia the cost of living is much more commensurate with the wage they are earning. That and they actually pay less for health care that everyone gets, which takes a huge burden off of people.

          In the US currently, people make so little that they are inextricably dependent on each paycheck, with no room to seek better work or demand better pay. The government provides food stamps and other assistance which allows these people to minimally survive at that wage so that the workforce doesn’t literally die off.

          I’ve also seen some analyses that show an increase to around $11/hr or so would alleviate a huge amount of governmental assistance burden and allow more people to be insured without actually affecting the cost of goods. Another one looked at McDonald’s and found that an increase in the wage of its employees to around the same level would lead to no necessary increase in the cost of food, but could conceivably lead to an increase of less than a dollar or so.

          Obviously these analyses are based on simplistic models of complex systems, so I wouldn’t trust the precise numbers and outcomes predictions. But the general idea behind it seems to be reasonable to me.

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