Nov 03 2008
“Urban Zen” and homeopathy at Beth Israel Medical Center, or: Dr. Gorski destroys his chances of ever being invited to join the faculty at BIMC or the Albert Einstein College of Medicine
I guess I never really wanted to work in Manhattan anyway. At least, that’s what I keep telling myself.
I mean, why on earth would I want to? What’s the attraction? Living in the heart of it all, all those shows and all those amazing cultural activities, all those world-class restaurants? Being close to Boston, Philadelphia, and other cool East Coast cities, which are all just a quick Acela train ride away? Who cares about those things, anyway?
Apparently I don’t, because I’m about to destroy my chances of working at what has been considered one of the premiere academic hospitals in New York City, specifically Beth Israel Medical Center, an academic affiliate of the Albert Einstein College of Medicine. It’s possible for me to have been ignored when I first included the Albert Einstein College of Medicine and its affliated Continuum Center for Health & Healing in my roll call of shame as a medical center that has not just added woo to its offerings, but actively embraced it. At the time I originally discovered it, though, its offerings seemed limited to fairly mild woo, the usual stuff like acupuncture, what I like to call “gateway modalities” that centers embrace first because they’re relatively tame and commonplace. All too commonly, though, dabbling in gateway modalities leads to the “hard stuff,” outright quackery with zero scientific basis like homeopathy, reflexology, and craniosacral therapy. Such is the pathway an academic medical center follows when it degenerates from science-based medicine to what Dr. R. W. famously dubbed “quackademic medicine,” usually driven by a few famous true believers, which, alas, is exactly what happened at fearless leader Steve Novella’s institution of Yale, thanks to Dr. David Katz and his “more fluid concept of evidence.”
In any case, last week, I realized that I’ve been completely neglecting the aforementioned roll call of shame. Perusing it, I now realize that it’s been over five months since I did a significant update to it. You just know that, given the rate of infiltration of unscientific medical practices into medical academia as seemingly respectable treatment modalities that there must be at least several new additions to this roll of shame. Alas, even today, having been shamed myself by the realization of my failure to keep the list updated, I’m not going to do the full update and revamping that the Roll Call of Quackademic Medicine cries out for. However, that doesn’t mean I can’t do a piecemeal addition here and there. That doesn’t mean I can’t point out new additions as they pop up, even if it takes me a while to find the time to give the list the facelift it cries out for. It doesn’t mean I can’t call out hospitals like Beth Israel when they fall into woo, especially when they dive into quackademic medicine in a big way for cancer patients.
The first thing to know about this degeneration of a once great academic powerhouse is that, as is the case for many centers of “complementary and alternative medicine” (CAM) or of “integrative medicine” (IM), when looking for the reason why physicians ostensibly dedicated to scientific medicine would embrace cult medicine, look for the financial motive. Indeed, as has been extensively documented by my cobloggers and myself, the National Center for Complmentary and Alternative Medicine (NCCAM) and the Bravewell Collaborative, spearheaded by extremely wealthy believers in unscientific medicine, are pouring millions upon millions of dollars to fund “research” and “training” (read: prosletyzing) for “complementary and alternative medicine” (CAM), a.k.a. “integrative medicine” (IM). In this case, the financial incentive comes from Donna Karan, founder of the famous DKNY line of clothing. In search of her dollars, Beth Israel has turned over an entire cancer treatment floor to woo:
Medical advances sometimes happen in strange ways. Someone finds a fungus in dirty lab dishes and — eureka! — penicillin is born. Now a premier Manhattan hospital is turning a cancer-treatment floor over to a world-famous fashion designer in the hope that serendipity, science and intuition will strike again.
A foundation run by Donna Karan, creator of the “seven easy pieces” philosophy of women’s wardrobes and founder of the much-imitated DKNY line of clothing, has donated $850,000 for a yearlong experiment combining Eastern and Western healing methods at Beth Israel Medical Center. Instead of just letting a celebrated donor adopt a hospital wing, renovate it and have her name embossed on a plaque, the Karan-Beth Israel project will have a celebrated donor turn a hospital into a testing ground for a trendy, medically controversial notion: that yoga, meditation and aromatherapy can enhance regimens of chemotherapy and radiation.
I can’t help but wonder here whatever happened to the days when a wealthy donor would be happy just to have her name on a building or on a floor. I guess those days never truly existed. Wealthy patrons frequently want more than just their names to live on in the form of a building or patient wing and always have. It’s the same reason they funded great artists hundreds of years ago. That’s not to say that such patrons don’t do truly great things with their money and influence. Certainly they can and do, as Evelyn Lauder has done in creating and running the Breast Cancer Research Foundation, which funds science-based research without giving in to the temptation to be trendy and fund research into unscientific modalities, largely thanks to Dr. Larry Norton, who is Chairman of its Executive Board of Scientific Advisors. In addition, my scientific hero, the late Dr. Judah Folkman, was funded by the BCRF for many years. (Full disclosure: I, too, am currently doing research funded by the BCRF. However, that aside, the more I’ve learned about the organization the more it impresses me. Just search the website for their research projects; you’ll be very hard-pressed to find even a hint of dubious research.)
All too often, unfortunately, wealthy patrons have a tendency to fund projects that serve to reinforce their own personal and non-science-based beliefs. Such is the case with Donna Karan funding this new oncology floor at BIMC. It’s truly depressing to see a former academic powerhouse accommodate such wishes just because they’re trendy, because a wealthy donor is willing to fund them, and because, no doubt, hospital administrators perceive it as good publicity and a potential draw for credulous patients. I wish I could view this as merely a cynical ploy to add a spoon full of woo to make the real scientific medicine go down easier, but somehow I fear that it’s more than that. There’s a big element of real belief in CAM and “spirituality” there. Indeed, it appears to be no different than what was discussed by Harriet Hall last week: An attempt to inject “spirituality,” which, let’s face it, when used in this context is almost always nothing more than a code word for trying to get medicine to endorse religion as a scientifically valid adjunct or primary treatment for various conditions. In other words, it’s the injection of religious belief into into medical practice in an inappropriate manner. The only difference is that, instead of “mainstream” Christian religion, in this case it’s Eastern mysticism in the form of yoga, which is composed not just of potentially useful low impact exercise but also a large amount of religious and spiritual beliefs. In the U.S., you can get your yoga relatively “spirituality”-free (most people do), but that’s not what Donna Karan appears to intend here, as you will see. In her proposed program, the “spiritual” elements of yoga are front and center.
There’s an old saying, though, that’s so famous and overused that it’s become a cliché, and that’s that the road to Hell is paved with good intentions. This is an excellent example of just that. Donna Karan hopes that her new “Urban Zen” center at BIMC will help patients deal with the side effects of chemotherapy, a worthy goal, to be sure. There’s no doubt that, depending on the specific regimen and patient, chemotherapy can cause very unpleasant side effects, and the alleviation of those side effects is an active and major area of research in scientific oncology, because not only are these side effects extremely distressing but they are sometimes so distressing that patients decide not to continue chemotherapy, thus reducing their chances of long term survival. Targeted chemotherapeutics with much lower toxicity and measures to alleviate chemotherapy-induced symptoms are right up there, close to being the Holy Grail of cancer research. Consequently, it’s hard to argue against trying yoga out for such an indication without seeming harsh and close-minded. I would argue that it’s bad to be so open-minded that your brains fall out.
To see why, observe what the program will involve:
Fifteen yoga teachers will be sent to Beth Israel’s ninth-floor cancer ward starting in January to work with nonterminal patients, and nurses will be trained in relaxation techniques. Their salaries, as well as a cosmetic overhaul of the ward, are being paid for by Ms. Karan’s Urban Zen Foundation, created after her husband and business partner, Stephan Weiss, 62, died of lung cancer in 2001.
While other hospitals in New York and across the country have dabbled in yoga, the new Beth Israel project is broader, better financed and more integrated into the medical protocol, and because of Ms. Karan’s concern that it might be dismissed as touchy-feely nonsense, it includes a research component. Ms. Karan hopes to prove that the Urban Zen regime can reduce classic symptoms of cancer and its treatment, like pain, nausea and anxiety (thereby cutting hospital stays and costs) and serve as a model for replication elsewhere.
In a couple of online discussions of this program, I’ve seen it asked: Wouldn’t that money be better spent funding the salaries of 15 RNs for the oncology unit? Almost certainly it would. But, as is the case with virtually all such efforts, this is about proselytization, not science-based medicine. Donna Karan is a believer, and she is looking for evidence to support her belief in order to justify further proselytizing of her Urban Zen program to other hospitals. It’s all very much like a religion, so much so that we’re hearing the usual excuses that that evil reductionistic “Western” medicine can’t adequately study whether yoga can do what is claimed for it:
But Dr. Benjamin Kligler, the research director in integrative family medicine for the Beth Israel-affiliated Continuum Center for Health and Healing and the research project’s principal investigator, acknowledged that the experiment of yoga teachers and their interaction with patients did not lend itself to the random, double-blind placebo trials favored in the medical world.
“The truth is, from a very traditional research perspective, that’s a problem,” Dr. Kligler conceded, adding that it might be time for the medical establishment to consider a new research model for what he called “lifestyle interventions.”
Even though a randomized, double-blind, placebo-controlled trial can’t be done in the classical sense, in most cases that’s nothing more than a convenient excuse used by true believers for not doing the most rigorous studies possible given the limitations placed by the specific modalities under consideration on what studies can be done. A classic example of this was published in the medical literature about a year and a half ago. It involved a study of Tai Chi as an immune booster. In fact, when looked at dispassionately and with a science-based eye, the study itself was not really a study of Tai Chi per se but rather a study of mild exercise versus no exercise in the elderly and whether mild exercise in the form of Tai Chi increased vaccine-stimulated levels of cell-mediated immunity (CMI) to varicella zoster virus in older adults. The results were predictable; it did. Of course, the positive results from that trial were attributed to the Tai Chi, rather than to mild, low impact exercise in general. After all, when stripped of all its Eastern mysticism, that’s all Tai Chi really is: low impact exercise. The huge, gaping hole in the study was that the only two groups in the study were the Tai Chi group and a group receiving passive health education. There was no additional no control group in which patients participated in another form of mild, low impact exercise without all the “spiritual” trappings to see if that had a similar effect. Ironically enough, yoga might have been a reasonable additional group, but any form of low impact exercise of the same intensity as the Tai Chi regimen used in this study would have been acceptable. It wasn’t there, and the authors didn’t seem to comprehend why their study didn’t show what they thought it did.
I’m expecting to see the same sort of studies coming out of Urban Zen at BIMC.
Of course, it’s not entirely unreasonable to hypothesize that low impact flexibility exercise might make people undergoing chemotherapy feel better, just as exercise makes people feel better, through whatever mechanism, be it distraction or a physiological effect attributable physical activity. Indeed, the scientific literature already contains studies suggesting that exercise speeds recovery from the adverse effects of chemotherapy and that it can reduce fatigue in patients undergoing chemotherapy. Whatever studies performed at Urban Zen are almost virtually assured to be “positive” simply because they encourage mild exercise in patients undergoing chemotherapy. However, this particular form of flexibility exercise, yoga, is overlaid with all sorts of “Eastern” mysticism that credulous CAM aficionados love so dearly, and it is the mysticism that Donna Karan believes in and wants to sell, not just mild exercise. It’s a classic “bait and switch,” although I’m guessing Karan has no idea that that’s what it is. She appears to believe, but belief is not science. It’s also depressing to think that a large part of what drives movements like this comes from the failure of our hospitals practicing science-based medicine to provide patients with a sufficient degree of human warmth and encouragement; I often think that the attraction of these touchy-feely non-science-based modalities would be much attenuated if we were able to provide more emotional support and our time to listen to patient concerns. Purveyors of woo are doing nothing more than seeing an opening and rushing in to fill it. The problem is that it’s not necessary to embrace religion or pseudoscience to fill this hole, and all the mystical and pseudoscientific baggage that accompanies such woo represents a profound threat to science-based medicine.
In any case, the “problem” that Dr. Kligler laments about testing yoga for this indication is really not nearly as big a problem as he makes it sound, certainly not big enough that we need a new paradigm to test CAM modalities scientifically. True, blinding is impossible for a study of the effect of exercise on chemotherapy-induced side effects, but we surgeons do unblinded randomized experiments in surgery all the time. After all, it’s rarely possible or practical to blind surgeons to the surgical procedure performed, nor is a sham surgery control group usually feasible. It’s a bit more difficult to get usable scientific data from clinical trials under such circumstances, but by no means anywhere near impossible. It just takes more effort to be rigorous elsewhere, and it usually takes more studies carried out at different institutions, to be sure to eliminate institutional and investigator biases as much as possible. Certainly, it’s not so difficult that we should consider jettisoning current clinical trial methodology, as Dr. Kligler seems to imply that we should.
Of course, it’s highly doubtful that Donna Karan would have tried to sell her yoga program to an institution not likely to be receptive to it, and, boy, oh, boy does BIMC qualify as being “open” to such ideas. Just get a load of its Continuum Center for Health & Healing. Peruse its webpage, and it’s a veritable cornucopia of woo and unscientific medical modalities. It’s all there. There’s reiki, Rolfing, prayer, Therapeutic Touch, traditional indigenous healing therapies, acupuncture, even that woo of woo, that One Quackery To Rule Them All (apologies to J.R.R. Tolkien), homeopathy:
As a pediatrician Dr. Stern finds that homeopathic medicines, which are safe and efficacious, are particularly well suited for the care of children’s common ailments. In her practice Dr. Stern uses homeopathy not only to treat acute problems such as upper respiratory infections and acute ear infections but also to treat more chronic conditions. For children suffering from conditions such as asthma, recurring ear infections, eczema and behavioral problems homeopathy has helped reduce or eliminate daily doses of antibiotics and steroids which are often required for symptomatic control.
Quackery such as homeopathy has no place in an academic medical center–or any medical center, for that matter. (There, I said it.) Worse, this quackery is being administered to children, and belief in homeopathy has led to unethical clinical trials with children as subjects. Homeopathy is water. Period. Diluting a substance does not render it more potent, nor does shaking it. Period. There is no plausible physiological mechanism by which homoepathy could work, and homeopathy goes against well-established science. Period. Barring incredibly compelling evidence for its efficacy in non-self-limited diseases, there is no reason to suspect that whatever effects are attributed to homeopathy are due to anything more than the placebo effect, regression to the mean, the expectation effect, confirmation bias, or a combination thereof. Period. Yet homeopathy is being offered at Beth Israel as though it’s on par with scientific medicine. Worse, its being promoted by true believers. Don’t believe me? Then consider this detailed and credulously positive description of homeopathy. I just about spit up my drink when I saw Samuel Hahnemann’s homeopathic provings as “meticulously executed experiments” (for an antidote, read Kimball Atwood’s post on “provings”) and indulged in appeals to ancient knowledge:
Although Hahnemann was the first to clearly formulate the law of similars and first began to use its principals in a systematic way, he clearly states that a number of people before him had very similar ideas. The “Law of Similars” has a very rich historical basis. Hippocrates (VI century, B.C.) wrote: “through the like, disease is produced, and through the application of the like it is cured”. Celsus and Paracelsus are known to have used the Law of Similars in their practice. The Delphic Oracle proclaimed:” That which makes sick shall heal”. In one of the ancient Jewish writings, called Mekilta, we read: “Man does not heal with the same thing with which he wounds, but he wounds with a knife and heals with a plaster. The Holy One, blessed be He, however is not so, but He heals with the very same thing with which he smites.” Modern medicine uses this principle daily. The “father” of immunology , Dr. Emil Adolph von Behring, wrote about the origins of immunology: “By what technical term could we more appropriately speak of this influence than by Hahnemann’s word “homeopathy”? Desensitization techniques used by conventional allergologists utilize very small doses of allergens to stop a pathological response in the patient.
If ancient knowledge is so great, I always ask whether believers in these ancient modalities would like to go back to the medical systems that existed thousands, or even 200 years ago (the time of Samuel Hahnemann) and see how well it worked compared to today’s scientific medicine. Right on cue after appeals to ancient knowledge are also appeals to popularity:
In England, Australia, New Zealand, India, Russia, Brazil and many other countries homeopathy is recognized as a valid mode of treatment. In the United Kingdom, around 42% of physicians refer patients to homeopathic practitioners, and homeopathic training is the most popular post-graduate training program. In France, approximately 36% of the public and 32% of the physicians use homeopathic remedies. Moscow, Russia, has a homeopathic hospital with a large homeopathic outpatient clinic and many homeopathic pharmacies with many people using various homeopathic preparations daily. India has approximately 125 four- and five-year homeopathic medical colleges with over 100,000 homeopathic doctors practicing around the country.
If you really want to throw up (homeopathically, of course), read another homeopathy article entitled Homeopathy — How it works and when to use it. The deconstruction of this article is left as an exercise for the reader. (“Decontruction”? How postmodernist of me!) I know you can handle such a task just fine. While you’re at it, feel free to take on the other woo on the Continuum Center for Health & Healing website. Suffice it to say it’s–shall we say?–a very, very “target-rich environment” for skeptics–depressingly so, in fact. It’s profoundly disturbing to find an academic medical center willing not merely to embrace such unscientific medicine but to actively promote it as science-based without a shred of evidence that any critical thinking whatsoever was applied to writing the material on the website touting its benefits.
Of course, no true floor dedicated to the “integration” of yoga and Eastern mysticism into our nasty, reductionist science-based medicine would be complete without real “integration” plus feng shui:
“A lot of other hospitals have integrative medicine, but it’s kind of stuck away in the basement,” said Dr. Merrell, who, not coincidentally, is Ms. Karan’s internist. “People like to think it’s not there.” Starting in November, the cancer ward will be renovated by Ms. Karan, the architect David Fratianne and Alex Stark, a feng shui master. The dull beige walls and green linoleum tile floors will be replaced with bamboo wallpaper and cork floors. Nooks and crannies now used for brown-bag lunches and naps and crammed with a desultory selection of dusty books will be turned into yoga, prayer and meditation retreats for patients, their families and nurses.
As I said before, this is religion–excuse me, “spirituality”–not science. And, true to most “alternative” medicine, it relies on testimonials. In this case, it’s the story of Lynn Kohlman, a photographer, model and DKNY fashion director who inspired Donna Karan with her battle against cancer. In fact, a quote by Karan is most revealing as to the true motivation for the Urban Zen center:
She [Kohlman] intensified her yoga. “She asked for it in the hospital,” said Ms. Karan, who practices yoga daily. “She needed it, she wanted it.
“This works,” Ms. Karan insisted. “Now we have to prove it in the clinical setting.”
That’s exactly the problem. Karan intensely believes that yoga “works” (although what “works” means in this context is not entirely clear), and she’s looking for evidence to support her belief, not to see if her belief stands up to experimental testing that could falsify it. There’s no malignant intent in her championing of yoga; after all, she thinks it will help people. However, her attitude of looking for evidence to support her preexisting belief rather than testing her belief, trying to falsify it, to see if it stands up to scrutiny is one key difference between scientific medicine and pseudoscientific medicine. Given Karan’s attitude, think about this: If the results of the “clinical trials’ being carried out at Beth Israel fail to bear out her belief, how long do you think her generosity will continue? CAM boosters frequently criticize trials of what they disparagingly call “conventional” pharmaceuticals because of perceived conflicts of interest due to the funding source. Make no mistake, this is indeed a serious problem in the research underpinning of science-based medicine, as I’ve pointed out before twice recently. However, with respect to programs such as Urban Zen, that argument cuts both ways. Don’t think that doctors running the “studies” of yoga at Urban Zen don’t know what their wealthy patron hopes that they will find in their “studies” of yoga and the relief of chemotherapy symptoms. Of course, any possible conflicts of interest may not matter. After all, they, like Karan, are true believers as well; so they want to find that yoga “works,” too.
I’m not opposed to patients using yoga because it makes patients feel better, and I’m certainly not opposed to using yoga as a form of mild (or even not-so-mild) exercise that may help ease recovery from the effects of chemotherapy. Exercise is good; exercise very likely helps patients who can do it deal with the side effects of chemotherapy. Remember, though, at its core that’s not really what the Urban Zen program is about, no matter how much Donna Karan and the boosters of quackademic medicine who have latched onto her belief and largesse at Beth Israel try to argue otherwise. I wish it were, but it’s not. No, in reality at its very heart it’s about the rejection of science in favor of a specific flavor of “spirituality” and the injection of that spirituality into the heart of the practice of oncology. It’s about the embrace of testimonial evidence over scientific evidence, and the abandonment of science and reason in medicine–or, even worse, their subversion to serve the beliefs of the people promoting these modalities. Again, none of this is because Donna Karan is evil or stupid. She truly believes she is doing good, but science doesn’t work the way she thinks it does. Worse, there are several enablers unwilling to disabuse her of her misunderstanding of science because to a greater or lesser extent they share her misunderstandings. To bring it all back home to the Urban Zen program, I’ll just say that, if you don’t believe me, take a look at the section on yoga on the Center for Health & Healing website:
What is Yoga? Most people think of Yoga as a physical practice of stretching the body in different ways. To some, Yoga evokes images of seemingly impossible contortions accomplished only by the adept. But the physical practice of Yoga is only one facet of a holistic system that addresses all aspects of our experience. The Sanskrit word Yoga literally means to yoke, bind, focus one’s attention; it also means union or communion. The ancient Yogis sought to experience our essential nature, beyond the bounds of body and mind. Through practice and discovery using the instruments of our very existence- the body, breath, senses and mind- they reconnected with the universal of which we are all an expression. This is the essence of Yoga. By moving into stillness through the layers of the body, emotions and thoughts, we find at our core a sense of deep peace and connection.
The science of Yoga is a guide to that peace. Recognizing the multifaceted nature of human beings, the system of Yoga addresses our complex relationship with the external and internal worlds. This system, called Astanga Yoga or the Eight-Limbed Path, encompasses Yama (ethical observances), Niyama (personal disciplines), Asana (physical postures), Pranayama (control of the breath), Pratyahara (drawing in of the senses), Dharana (concentration), Dhyana (meditation) and Samadhi (higher consciousness). These Eight Limbs are like rungs on a ladder; each one is an important step on the path and leads naturally to the next.
In the Yogic view, disease is the result of imbalance. Yoga approaches dis-ease by restoring ease. To understand the benefits of Yoga it’s helpful to first look at one of the roots of dis-ease-stress. Sometimes in the absence of an identifiable cause of a condition, we assume “it must just be stress.” But the effects of chronic stress are quite specific and in a very real way lead to illness if unchecked.
What is stress? The stress response (“fight-or-flight”) is a survival mechanism that enables us to respond quickly to dangerous situations. In the face of a perceived threat, a cascade of physiological events takes place that prepares the body to get itself out of trouble. Stress hormones are released, heart rate and breathing rate increase, blood vessels constrict, blood pressure increases, muscle tension increases, resting processes such as digestion and repair cease, immune function is impaired, fats and sugars are released into the bloodstream, and insulin production increases. Fight-or-flight is carried out by the sympathetic nervous system, part of the autonomic nervous system.
Ideally when the emergency is resolved, the body returns to its natural state of balance. But because the stress response is nonspecific, it may be set off by events, thoughts and feelings on a daily basis. Without relief, without restoring balance, the state of stress can become a chronic condition and we become vulnerable to illness.
Aside from all the “balance” blather, a good rule of thumb is that whenever you see the word “disease” spelled as “dis-ease” you can be quite confident that you’re dealing with grade A, top-notch woo. Snark aside, though, no wonder Donna Karan saw the faculty at BIMC as kindred “spirits” and decided to shower her patronage on them, who in turn were apparently more than happy to accept her largesse and run with it. No doubt in future years, there will be a series of publications arising from BIMC and the Albert Einstein College of Medicine touting the benefits of yoga for chemotherapy-induced nausea and other symptoms. No doubt they will fail to include critical controls, just as the Tai Chi study I discussed did. And no doubt they will be uncritically trumpeted in the press, particularly given the publicity engendered by the well-meaning but unscientific benefactor of the Urban Zen effort, Donna Karan. Albert Einstein, if it were possible for him to know what sort of pseudoscience is being perpetrated by members of the faculty at the medical school bearing his name, would proceed to do backflips in his grave.
And, no, I guess I don’t want to live in New York that badly after all. In fact, I’m quite happy with my current position, and I wouldn’t fit in with the “holistic” approach at BIMC anyway. Besides, in the unlikely event I ever became disenchanted with my current job and decided to relocate again, I’d much rather move to Chicago than New York anyway. I’m a Midwest guy at heart.
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