Dec 12 2008
Recents posts by Drs. Albietz and Gorski have highlighted questions that are recurrent on SBM. We are convinced that medicine should be based on real knowledge, to the extent that it exists, and that physicians should be honest; these are matters of science and ethics. How do we reconcile that with heartfelt, if misguided beliefs of patients, their families, and others? When Dr. Albietz wrote that it might have been better for the chiropractor to visit in the same way that “priests, imams, prayer sessions, rabbis, etc visit children within the PICU,” it was reminiscent of Dr. Peter Moran’s hypothetical “witch doctor.” When he lamented academic medicine’s current dalliances with quackery, it brought to mind the NCCAM, David Katz, Andrew Weil, Bravewell , and their enablers.
Dr. Albietz argued that when talking to credulous patients or their families, taking a hard line against quackery is likely to be counter-productive. Most of us would agree with that. Dr. Gorski described a different scenario: after calling a quack “a quack” when talking to a friend of a friend who is a scientist, he concluded that he had been too “blunt.” Several commenters disagreed, but all would probably agree with Dr. Gorski that “you have to know when to pick one way over another; i.e., diplomacy over all out war or vice versa.”
Another Case of Foot-In-Mouth Disease
I recently had an experience strikingly similar to Dr. Gorski’s, during which I castigated myself for my rancor even as I was incapable of moderating it. Fellow blogger Dr. Val Jones was a witness!
A couple of weeks ago there was a meeting in Philadelphia of those involved with, or otherwise interested in the Health Care Renewal (HCR) blog and its related organization, the Foundation for Integrity and Responsibility in Medicine (FIRM). The blog had been started several years ago by Drs. Roy Poses of Brown, Wally Smith of Virginia Commonwealth University, and Russ Maulitz of Drexel. Those three docs lamented recent threats to the core values of medicine:
The Problem: Health care around the world is beset by
- rising costs
- declining access
- stagnant quality
- increasingly dissatisfied health care professionals.
Physicians fear their core values are threatened. These values include:
- putting the interests of individual patients ahead of other concerns;
- practicing with honesty and integrity;
- keeping patients’ information confidential;
- teaching the next generation of health professionals;
- practicing medicine based on science and scientific principles.
Strong but generally unrecognized threats to these values arise from concentration and abuse of power in health care systems, because:
- health care is increasingly dominated by large organizations;
- these are often lead by the ill-informed, the self-interested, and even the corrupt.
Thus, the results are:
- patients and physicians are caught in cross-fires between conflicting interests;
- patients and physicians are subject to perverse incentives;
- free speech and academic freedom are threatened;
- pseudo-science and anti-science are gaining ground.
You can see, especially in the last bullet, why I was attracted to this group. After years of email discussions and blogging, the principals convened a one-day meeting to consider how the movement might grow. It attracted about 50 people from a variety of backgrounds: academic and practicing physicians, medical informatics experts, at least one medical student, the editor of the Annals of Internal Medicine, health policy researchers, a few reporters, my co-author and president of CIRCARE Liz Woeckner, Dr. Val (who had just finished sitting on a panel with Roy Poses at a different meeting), several lawyers (including frequent SBM commenter Marilyn Mann), and more.
There was a dinner at a local restaurant the night before the meeting. About 18 participants were there, spread among 3 tables. I sat between Dr. Val and a physician I’d not previously met, whom I shall call Dr. O. The ambient noise level was high, so most conversations involved only 2-3 people. I can’t remember how it started (did she ask me how I came to be involved with this group?), but at some point I heard myself explaining to Dr. O that I was skeptical of implausible medical claims. That soon led to my offering homeopathy as an example of a claim that doesn’t warrant the slightest credibility, and certainly doesn’t warrant clinical trials.
It might have been then that Dr. O said something like, “I’m a faculty member at the first science-based CAM program in the country.” The inherent contradiction aside, that was a show-stopper if there ever was one. It began to dawn on me that I knew who she was: a “CAM” researcher who has stuck to the relatively plausible end of the “CAM”-scale, namely botanicals, and who has published articles that seem reasonable—when viewed through the prior probability-impoverished lens of Evidence-Based Medicine—if banal. Dr. O has also written some more interesting and useful articles about how industry has influenced medical research and practice, including examples of ghostwriting of papers and effects on prescribing patterns. It is the latter activity that drew her to the HCR/FIRM group and vice-versa.
Dr. O continued by observing that the “homeopathy debate” is a vigorous one among her colleagues, with about equal numbers believing that homeopathy does or doesn’t work. She suggested, however, that all of them agree that it ought to be tested, and didn’t I as well? No, I didn’t; or, more precisely, there have already been billions and trillions of tests of homeopathy, in the form of purposeful or incidental tests of the 2nd law of thermodynamics, and no small, error-prone clinical trials could possibly overthrow those findings. I hoped to make a general point about prior probability that might get her to entertain a more scientific point of view; I wanted to summarize arguments made here and here in just a few sentences. Alas, ’twas not to be.
I’d barely taken my next breath when she said something like, “but how can you dismiss all of CAM research? There are some brilliant CAM researchers!” Yikes. I should know that feeling by now: she got my goat and I was about to say things that I might later regret:
“Who, for example?”
“So and So.”
“So and So? So and So is a fraud!”
“HOW can you say he’s a fraud? So and So is one of my dearest friends!”
“For one thing, his [degree] isn’t even real!”
“That’s not true! [His] medical school looked into that and found out that it was real!”
“Oh yeah? I’d love to see the evidence. I was one of the people who asked [his] medical school to look at the issue, and I doubt that they did it in a thorough way.”
“YOU DID THAT? Do you realize the hell that he went through because of that?”
It was loud in the restaurant, and I missed a lot of what she said next, but I’m pretty sure she called me “a miserable human being.” Shortly thereafter she got up and left, although dinner was barely half over. I’d made an attempt to salvage the conversation (“why don’t we talk about this some other time when we’re more calm and can hear each other better?”), but she was having none of it.
As soon as she left I turned to Dr. Val, who had gleaned but a small amount of what had just happened, and said something like “I can’t believe what an idiot I was. WHY did I have to say that?” Even though, like Dr. Gorski, I believed everything I’d said. The point is, “you have to know when to pick one way over another,” and sitting in a loud restaurant next to someone you’ve just met, who probably assumes that you share fundamental views about medicine, isn’t a time to pick “all out war.”
It’s funny: I got the feeling that Dr. O was more surprised by me than I was by her. I wondered why. Wasn’t she aware that two of the group’s perceived threats to medicine’s core values were “pseudo-science and anti-science”? Had she read a paper written by Roy Poses a few years ago, in which he elaborated on the bulleted points quoted above? In a section entitled “Attacks on the scientific basis of medicine,” Dr. Poses wrote:
Postmodernists argued that clinical trials became pre-eminent not because they are less susceptible to selection bias than are observational studies, but because they somehow gained more political support than did other methods, e.g., ‘in a self-authenticating manner, the double-blind RCT became the instrument to prove its own self-created value system’.’’
Postmodern arguments also underlie some of the current enthusiasm for alternative medicine. For example, …the editors of a prominent published series on alternative medicine…asserted the ‘old cultural war of a dominant culture versus heretical rebellion in politics and religion as well as medicine has begun to transform into a recognition of postmodern multiple narratives’.”
If Dr. O had read that paper, she would have known that the quoted PoMo drivel had been written by none other than…So and So! Copies of the paper were handed out at the meeting; I wonder if she’s read it by now.
The Changing Etiquette of Criticism
The whole matter got me to thinking, for the umpteenth time, about how American society’s view of acceptable criticism seems to have changed in the recent past. Calling a thing by its name, even if unflattering, used to be honorable; now it’s considered shrill, or worse, mean. When Oliver Wendell Holmes, Sr., discussed the views of his contemporary, Samuel Hahnemann, he didn’t give what is now called a “balanced” presentation. Responding to Hahnemann’s claim in the Organon—”It was by these means” (i.e. Homeopathically) “that the Princess Eudosia with rose-water restored a person who had fainted!”—Holmes wondered:
Is it possible that a man who is guilty of such pedantic folly as this—a man who can see a confirmation of his doctrine in such a recovery as this—a recovery which is happening every day, from a breath of air, a drop or two of water, untying a bonnet-string, loosening a stay-lace, and which can hardly help happening, whatever is done—is it possible that a man, of whose pages, not here and there one, but hundreds upon hundreds are loaded with such trivialities, is the Newton, the Columbus, the Harvey of the nineteenth century!
Such stark criticism was still de rigueur only a few decades ago. At the HCR/FIRM meeting, Dr. Scot Silverstein told of his mentor, the cardiac surgeon Victor Satinsky, who had argued “that ‘use of public embarrassment’ was an effective tool in dealing with the corrupt.” It was during his Summer Science Training Program for gifted high school students, taught at the Hahnemann Hospital, of all places, that Satinsky had made that statement.
I realize that this lamentation—the degradation of good criticism in our time—does not apply to such scenarios as Dr. Gorski’s with his friend’s friend or mine with Dr. O. In my case, it was a matter of matching the presentation to the occasion, and I’m afraid I did not do that very well. Nevertheless, we must insist, in the relevant venues, on being honest and unyielding in our criticisms of quackery.
Near the end of the meeting day, I saw Dr. O again. She appeared to be in a conciliatory mood; she even asked me if I would be walking to the train with a few others, including her. I would not be, but I got the impression that there might have been just a scant possibility of communicating without rancor. Maybe not: the charge that I had made is a serious one. Perhaps one day I’ll write about it here, using real names.
The greater issue involving science, medicine, ethics, honesty, and language is even more serious. Dr. Albietz correctly worried that “the next generation of physicians, immersed in the mutually exclusive principles of CAM and EBM, will be poorly prepared to provide the best possible care to their patients.” If the “open forum” that follows the article linked from the first mention of Dr. Poses’ name above is any measure, “poorly prepared” is an understatement.
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