Dec 08 2008
BLOGGER’S NOTE: The incident described in this post is true, although somewhat embellished to protect the names and identities of the innocent, if you know what I mean. This conversation occurred a few years ago at a large national cancer meeting.
The question caught me by surprise.
While attending a large national cancer meeting, I was having brunch with a friend, a colleague with whom I used to work when I was doing laboratory research, someone whom I hadn’t seen in a long time. She and her husband had brought along two of their oldest and dearest friends, whom they had known for decades, as well as another of my former coworkers from my old lab. We were idly chatting away and eating, when one of the occupational hazards of being a doctor presented itself. Tthe conversation drifted to medical topics. And then it came.
“What do you think of Dr. Gonzalez?”
Blindsided again! Why hadn’t I seen that one coming? As a doctor, I find that these sorts of questions hit me when I least expect them. I was half-tempted to play dumb and pretend that I didn’t know who Dr. Gonzalez is, but decided against that approach. It doesn’t work anyway. I knew feigning ignorance would only result in her telling me who Dr. Gonzalez is in excruciating detail. Instead, I asked a single question to make sure we were both on the same page and talking about the same Dr. Gonzalez, “Do you mean the Dr. Gonzalez in New York City, the one who uses ‘detoxification,’ diet, and enemas to treat cancer?”
“Yes, that’s him,” she replied.
No escape there. For those of you who aren’t aware of who he is, Dr. Nicholas Gonzalez is a physician in New York City who claims to be able to treat incurable cancers with a regimen that includes dietary manipulations, “detoxification” with coffee enemas, and the ingestion of pancreatic enzymes. I’ve discussed him before in the context of a patient who followed his regimen and paid a price and, indeed, who might even have been treated by Dr. Gonzalez himself back in the mid-1990s. My co-blogger Dr. Atwood has produced a series of blog posts (1, 2, 3, 4, 5, 6) that will tell you in exquisite and painful detail. Dr. Gonzalez’s methods are based on a regimen popularized by William Donald Kelley, D.D.S., whose regimen resembled that of Dr. Max Gerson (whom I’ve written about). Using this regimen, Dr. Gonzalez claims that he can produce long-term survival in patients with inoperable pancreatic cancer, for whom the median survival is usually less than six months. Never mind that his study only had 11 patients who could complete the regimen, had no control group, and, given the rigor of the regimen required, had the potential for serious selection bias (Gonzalez’s regimen can sometimes require as many as 150 pills per day). Based on this tiny uncontrolled study, somehow NCCAM saw fit to fund a $1.4 million clinical trial, for which my co-blogger Dr. Atwood has produced compelling evidence that the Gonzalez regimen did not work and, indeed, may have even produced worse results than conventional therapy. As I’ve said before, if I were to submit a grant proposal to the NIH with so little preliminary data, the study section would have a good laugh at my expense before filing my application in the cylindrical file. In fairness, I will give Dr. Gonzalez a modicum (but just that!) of credit for at least making an attempt to use science to look at his therapy, however dubious the supporting data. Too bad he apparently wasn’t intellectually honest enough to report the results when they almost certainly didn’t go his way.
I wasn’t in the mood, though. I had just wanted to hang out with some old friends and talk about science, old times, and other topics. Also, I knew that a debunking session would probably not be appreciated (they almost never are, particularly in what was supposed to be a light social situation), and I didn’t want to risk offending my friends by being too strident with their old friend. So I tried to discourage her. “You probably don’t want to know what I think,” I replied, with what I hoped was a self-deprecating smile and chuckle.
“No, I do,” she said.
Damn, she’s going to be persistent, I thought. Not in the mood for a confrontation, I became more insistent. “No, I really don’t think you do.”
“Please.” She leaned forward, expectantly.
“You’re probably not going to like it,” I gently warned her, feeling like Deep Thought preparing to reveal after seven million years of working on the problem that the answer to the Great Question of Life, the Universe, and Everything is 42. If she didn’t know what I was going to say now, I would no longer be responsible for what came next.
OK, I warned you. “He’s a quack,” I blurted out, wincing inwardly at how it must have sounded coming out. “I see no evidence that his ‘therapies’ do anything for cancer patients.” Did you have to use the q-word? Why couldn’t you be more diplomatic? I rebuked myself. You know what you normally do in these cases. You normally say that the treatment is unproven, that there is no evidence that it does anything whatsoever to increase long-term survival in cancer patients, but that you doubt it does any harm. (Even if you don’t necessarily believe that inside for this particular therapy.) That’s how you defuse the situation, avoid unpleasantness, and even possibly educate the people asking about the questionable therapy. You don’t use the q-word!At least, you don’t use the q-word with well-intentioned people who just don’t know any better. Hard-core alt-med mavens, on the other hand, are another matter entirely.
She was silent for a moment. Silverware clinked, but no one spoke. Everyone, my friend included, was looking at me expectantly.
I began a discussion of why I held the opinion I did about Dr. Gonzalez. I was starting to explain that Gonzalez’s methods were based on out-dated, faulty, turn-of-the-century concepts of how cancer developed, how his concept that cancer is due to a deficiency in pancreatic enzymes is not only implausible but not supported by scientific evidence, how there was (at the time) no good randomized clinical study that shows his methods do anything for cancer patients, and how the only reason his methods hadn’t gone the way of Laetrile was because of aforementioned tiny study, which led to the NCCAM study, when my friend’s friend interrupted. “You know, my husband and I know one of Dr. Gonzalez’s patients.”
“Oh, really,” I said. So that was why she was so interested.
“Yes, he had melanoma. His doctors told him he should just go into hospice or go home to die. But he went to Dr. Gonzalez, and he’s been fine. That was 12 years ago.”
Ah, geez. The dreaded “the doctors sent me home to die” cliché of so many alternative medicine cancer cure testimonials–even worse, the testimonial told second-hand to a friend. You can’t effectively fight that one without risking serious unpleasantness, and I didn’t want things to get too unpleasant, in deference to my friends. I realized that there was no way I was going to convince these people that Gonzalez was using unproven–even harmful–methods with no evidence of efficacy. They believed he had saved their friend’s life when no other doctor could. I also realized that questioning them to see if I could figure out whether their friend really did have metastatic melanoma was probably pointless. I guessed that most likely their friend probably didn’t have stage IV melanoma and that surgery probably took care of the disease, as it does for the vast majority of melanoma patients who survive the cancer. (Lay people and even some physicians not familiar with melanoma frequently confuse “stage IV,” which does mean metastatic and, with few exceptions, incurable with Clark “level IV,” which does not, unless the melanoma is accompanied by distant metastases.) But people won’t believe that or hear it when you say that. Indeed, in my experience, lay people rarely have enough information to let an oncologist or cancer surgeon assess the true severity of their friend’s or relative’s illness.
So I did the only thing that was left to me. I explained that a single anecdote does not constitute evidence for general efficacy, using one of my favorite sayings, “The plural of ‘anecdote’ is not ‘data.’” I also explained that spontaneous remissions, although very rare, do occasionally occur for melanoma and that it was impossible to assess whether the Gonzalez treatment really worked or whether conventional surgery had taken care of the melanoma. (Remember, when patients undergo surgery and then decide to opt for alternative medicine for the remainder of their treatment, they almost always attribute their “cure” to the alternative medicine, and not to the surgery.) Finally, I pointed out that my skepticism was rooted in both the lack of evidence that Gonzalez’s therapy does any good and the flawed “model” of cancer upon which the Gonzalez therapy is based. I told them that it was being studied in a clinical trial but that I sincerely doubted that it would be shown to have much, if any, benefit. I also explained the concept of selection bias, and how the healthiest patients were the ones who could manage to go through Gonzalez’s rather rigorous regimen, which could include as many as 150 pills a day.
“Oh,” she said. “You know, I heard of another person that Dr. Gonzalez had turned down because he had had so much chemotherapy and other treatments before.”
“That doesn’t surprise me and only makes me think selection bias even more,” I replied.
Perhaps I had gotten through after all–maybe just a little. It also helped that everyone at the table except them were scientists involved in medical research. I got a little tactical air support from them.
The conversation moved on to other topics. I did see everyone again a couple of more times while in Anaheim, and, to my relief, the topic of Dr. Gonzalez never came up again.
But this encounter reminded me of a few things. First, credulity will hit you when you least expect it. Most people who believe in these things aren’t hardcore alt-med aficionados. They are regular people who just don’t have the background in science and critical thinking to assess claims of “unconventional” practitioners properly. Second, many of these people can be educated, but not by stridency or overly strong attacks on their favored practitioner. That’s why I winced when I let it blurt out that I thought Dr. Gonzalez was a quack, even though I do, in fact, believe that he is. That could have turned them off so completely that anything else I said would have been ignored. (Fortunately, it didn’t, but it could have.) It also reminded me when, out of the blue, a couple of my close relatives expressed to me the belief that Sylvia Browne could really communicate with the dead. Suffice it to say that I did not cover myself with glory in terms of communicating skepticism and critical thinking, even to my family. Indeed, I recall yelling and the liberal use of terms like “bullshit,” “con artist,” and “scammer,” among others. True, Sylvia Browne is all of those things and her claims to be able to speak with the dead are, in fact, bullshit, but using those terms probably did not change any minds.
Blogging is one thing; being blunt is often appropriate here because the modalities that we are talking about are often not just useless but actually harmful. Moreover, to engage the reader, we have to be at least somewhat entertaining to read, and it is entertaining to read a sarcastic deconstruction of quackery. Also, reading a blog post or an article is not the same as having someone call quackery to your face. Face-to-face encounters usually require a different, more diplomatic approach, which is, believe it or not, possible without compromising. I also believe that the same (usually) holds true for radio and television, where it is very easy for believers to paint the skeptic as angry and intolerant, just as creationists have been doing to defenders of evolution for years whenever one is tempted to accept invitations to debate creationists. Finally, if you’re a skeptic and a doctor, you have to be prepared at any moment to do your part for science- and evidence-based medicine and against quackery. And remember, don’t resort to bluntness until you’ve exhausted more diplomatic means of getting your message across–unless you’re dealing with a hardcore believer, of course, in which case diplomacy is probably pointless unless there are others around whom you don’t want to turn off. The old saying may point out that there is more than one way to skin a cat, but you have to know when to pick one way over another; i.e., diplomacy over all out war or vice versa.
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