September 26, 2002Kimball Atwood, M.D. xxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxx
I have now had time to look into the allegations in your letter of June 14th which, incidentally, I shared with Dr. David Eisenberg and he with several others. I have sought consultation about our exchanges and the gist of my response follows.
Some of your concerns and allegations are very helpful and constructive. Perceptions are particularly important in controversial fields where there is limited objective proof. Your cautions and interpretations in this area have been very useful to us.
Some of what you said is just plain wrong. This includes the allegation the Harvard has “a stake” in the area and therefore would not look into your allegations objectively. Relatedly, Dr. Howard Koh has written us a construction of the events in the Massachusetts Special Commission that is strikingly different from yours. And Dr. Anthony Komoroff has pointed out that many of your comments about the InteliHealth treatment of CAM are now grossly out of date as the material inherited from another provider has been reviewed by HMS faculty and modified. [Indeed, you have referred in other correspondence to modifications you have noticed.] Dr. Komaroff also commented on the misleading way your citation the treatment of homeopathy was disconnected from the rest of the paragraph.
Some of what you said is a matter of taste or interpretation, where even well intentioned people may disagree. In this particular area I have weighed your arguments carefully and, in places, learned from them.
But I think the biggest difference may be in a misperception about what our purposes are. The Council of Academic Deans of Harvard Medical School approved beginning a Division of Research and Education in Complementary and Alternative Therapies with exactly the focus described. Our goal is to do peer-reviewed basic and clinical research on the claimed, but unproven, efficacies of complementary and alternative approaches to therapeutics. The recent scientific sessions and requests for proposal held by the Division are clear testament to this intent. In addition, in common with the Association of American Medical Colleges and most of the allopathic schools of medicine, we intend to teach our students something about CAM and in particular how to assess its claims rigorously. We do not, repeat NOT, have any intention of making our students CAM practitioners. They have enough to do learning what we have always focused on.
Daniel D. Federman, M.D.
cc: David M. Eisenberg, M.D.
Recent comments on homeopathy again resulted in references to the 1994 Pediatrics paper by Jacobs et al on use of homeopathic remedies for childhood diarrhrea. The authors of that paper concluded from their blinded study that homeopathic remedies, tailored to the individual infants and children, were effective in reducing the number of diarrhea stools and thus in shortening the illness. The paper has been widely referenced and reported to have proved homeopathy efficacy, and the critiques have been argued by homeopaths as irrelevant, as has been done by Mr. Ullman.
In this short series I want to recount my experience with the report, its predecessor, and its two major sequellae, as well as its effect on systematic reviews of homeopathy. I will begin with a description of the first two studies, concentrating on their methods. Then I will discuss the results of the 1994 Pediatrics report and the authors’ interpretation of the results. Then (I hope last) I will discuss the third paper which the authors claimed supported findings of the first two and the meta-analysis which combined data from all three. If you are imagining why this series interests me, and imagining the worst, you are probably right. The sequence will help to reveal how some of the information in “holistic” and “alternative” systems become published, and despite critiques and disproofs through a sort of systematic deconstructions, still develop wheels of their own and enter the fund of general knowledge seemingly forever. Or, at least for several decades, until a social belief switch is finally turned off.
After my fairly recent awakening from shruggieness (i.e. a condition in which one is largely unaware of or uninterested in CAM) I decided to discuss my concerns about pseudoscience with my friends. One particular friend is a nationally recognized physician who believes in the importance of accurate health information and the promotion of science. However, he sees no urgent need to warn people against snake oil, and so long as it’s correctly labeled he doesn’t seem to mind it co-existing with scientific alternatives.
My friend and I had dinner a few weeks ago, and our conversation was both animated and disappointing. I somehow felt inadequate in conveying my objections (both ethical and scientific) to the promotion of pseudoscience. My best explanations were met with cheerful rebuttals, and while not intellectually convincing to me, those retorts satisfied my friend just fine. I guess the bottom line was that he was more interested in maintaining his position than reconsidering it… and so it left me feeling rather frustrated and a little sad.
Recently my co-blogger David Gorski wrote an excellent analysis of the latest propaganda effort from the anti-vaccine crowd – a website that attempts to deconstruct the fourteen studies most often cited to argue for a lack of association between vaccines and autism. As David pointed out, there are many more than 14 studies which demonstrate this, and no credible studies showing that there is any correlation. David covered some of the 14 discussed studies, and today I will discuss one more.
On that anti-vaccine propaganda site J.B. Handley begins his introduction with this logical fallacy:
Of all the remarkable frauds that will one day surround the autism epidemic, perhaps one of the most galling is the simple statement that the “science has spoken” and “vaccines don’t cause autism.” Anytime a public health official or other talking head states this, you can be assured that one of two things is true: they have never read the studies they are talking about, or they are lying through their teeth.
Of course this is a false dichotomy, or forced choice. I personally know of many people, including myself and David, who have both read all the studies and are telling the truth about our opinions that they do not support a link between autism and vaccines. It seems to be inconceivable to Mr. Handley that an informed professional could honestly disagree with his opinions – such is the nature of fanaticism.
Back in February, an acupuncturist in Key West, Florida, was arrested on charges of using a physician’s credentials to obtain controlled substances and other prescription drugs. While some of these drugs were for the individual’s personal use, the Key West Citizen reported from arrest records that the acupuncturist had obtained other drugs for her patients, including anxiolytics, a muscle relaxant, and sedative sleep aids.
While it is not clear if the individual in question specifically mixed those drugs with herbal or homeopathic remedies available at her practice, the demographics of her clientele are likely to be inconsistent with the use of prescription drugs.
Why do I propose this hypothesis and where would a practitioner get the idea to mix prescription drugs with herbal products to make them appear effective?
Why, the dietary supplement industry, of course.
I have been asked to review a pre-publication proof of a book that will be published in May 2009: Evolution Rx: A Physician’s Guide to Harnessing Our Innate Capacity for Health and Healing by William Meller, MD. It offers “a primal yet radical new view of why we act and feel the way we do, why we get sick and how we heal. This new perspective, known as evolutionary medicine, looks at how our Stone Age ancestors lived, loved, got sick and got well over millions of years, which leads to guidelines for living longer healthier and happier lives today.”
He says we are the way we are because that’s what it took to adapt and survive throughout our evolutionary history. To some extent, that’s true, but that’s not the whole story. Sometimes we are the way we are because of an accident of evolutionary history that had no bearing on survival. Sometimes we are the way we are because a useless trait was linked to a useful one and came along for the ride – what Stephen Jay Gould referred to as “spandrels.”
The problem with evolutionary explanations is that we can never know for sure if they are true. We may be inventing “Just So Stories” like Rudyard Kipling’s “How the Camel Got His Hump.” Our explanation may seem perfectly reasonable but we may not have all the information and there may be a better explanation that simply doesn’t occur to us. (more…)
In this space we’ve read about the efforts of “alternative” practitioners such as naturopaths to gain the moniker “primary care provider”. I’ve been wondering a bit about this. I’m a primary care physician. Specialists in internal medicine, pediatrics, and family medicine provide the bulk of primary care in the U.S. They attend a 4-year medical school, complete a 3-4 year residency, take their specialty board, and then work as experts in the screening, prevention, diagnosis, and treatment of common diseases.
So, what I’d like to do is give you a typical scenario from an internal medicine or family medicine practice. It’s a simple one, one you might see on Step II of the USMLE boards or on a shelf exam for an internal medicine rotation. I’d like to offer alternative practioners, especially naturopaths, an opportunity to show how they would approach the clinical scenario so that we can see what kind of primary care they provide.
Yes, every patient and every situation is different, but there are some general ways to approach health and disease based on the evidence.
Welcome back, my friends, to the show that never ends, part II: Generation Rescue, the anti-vaccine propaganda machine, and “Fourteen Studies”
I hadn’t planned on writing about the antivaccine movement again this week, so soon after having had to subject myself to yet another round of Jenny McCarthy on Larry King Live and a truly execrable Generation Rescue “study.” I really hadn’t. For one thing, there’s just so much nonsense laid down by antivaccinationists these days that it’s utterly impossible for one blogger to keep up with it all. I could write about them every single day and still not counter the sheer mass of pseudoscience, misinformation, and general ignorance that antivaccine activists spout each and every day, and because this is Autism Awareness Month lately the misinformation has been coming particularly fast and furiously. Sometimes, however, there arrives a bit of misinformation that is so egregious that it requires some response, regardless of how burned out on the topic I might be; so I guess I’ll just have to suck it up and plunge into the morass again.
The reason is that, in retrospect, I now realize that the Jenny and Jim antivaccine propaganda tour was clearly merely phase I of Generation Rescue’s April public relations offensive. In rapid succession last week, courtesy of J.B. Handley, the founder of Generation Rescue, who in order to have a couple of famous faces fronting his organization has allowed himself to be displaced, so that Generation Rescue has now been “reborn” as Jenny McCarthy and Jim Carrey’s Autism Organization (the better to capitalize on her D-list celebrity yoked to Jim Carrey’s formerly A-list (but rapidly plunging) celebrity), announced Generation Rescue’s latest initiative in a post on its antivaccine blog Age of Autism entitled Fourteen Studies? Only if you never read them.:
I’m a primary care physician. What I, other internists, pediatricians, and family medicine docs do is prevent and treat common diseases. When we get to diseases that require more specialized care, we refer to our specialist colleagues. There is a movement afoot to broaden the role of naturopaths to make them primary care doctors. The big difference between naturopaths and real primary care physicians (PCPs) is that naturopaths haven’t gone to medical school, completed a post-graduate residency program, and taken their specialty boards. Why is this important? If a naturopath wants to be a PCP, then they must provide the same services as other PCPs. They do not. What, you don’t believe me? The thing is, naturopaths have an incorrect understanding of human biology and do not understand how this is applied in a science-based fashion to prevent and treat human disease.
Naturopathic “physicians” claim that “the human body has an innate healing ability” and that they “teach their patients to use diet, exercise, lifestyle changes and cutting edge natural therapies to enhance their bodies’ ability to ward off and combat disease.”
I must admit that I don’t get it. As a primary care physician (the real kind) I talk to my patients every day about diet, exercise, and lifestyle changes. I’m not sure what “natural therapies” are—all of the medications that I prescribe are “natural”. What is the opposite of natural? Unnatural? Supernatural?
Kimball Atwood is obviously trying to throw mud at Harvard and at homeopathy, but when you throw mud, you get dirty…
(Sigh) So little time, so much misinformation. Hence the Dull-Man Law:
In any discussion involving science or medicine, being Dana Ullman loses you the argument immediately…and gets you laughed out of the room.
This will be the last time that I don’t invoke that law, because it is the perfect opportunity to explain why it is such a useful shortcut. The occasion is the current series about my alma mater, Harvard Medical School (HMS), and its regrettable dalliances with quackery.† The series consists mostly of correspondence that occurred between Dean Daniel Federman and me in 2002. Some of it refers to homeopathy.*
Mr. Ullman, a self-styled expert on homeopathy who lacks any medical training, is a darling of the ‘integrative medicine’ movement, as explained here. He has posted several comments objecting to my assertions in the HMS series. Other commenters have skillfully refuted some of his arguments. Some have been left unchallenged, however, and a naive reader might therefore assume that they are valid. They are not, but explaining why takes time and a modest acquaintance with the topic. Other than to clarify the issues for the uninitiated, then, such time would be wasted. Henceforth, let it not be so: From now on, this post can be cited by anyone wanting to avoid the drudgery of refuting Mr. Ullman’s claims. (more…)