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The New England Journal of Medicine Disappoints

On July 31 of this year, a collective groan could be heard emanating from critics of pseudomedicine. The causative factors (which is medical bombast for “the cause”) were two book reviews published in the usually staid New England Journal of Medicine (NEJM):

Integrative Oncology: Incorporating Complementary Medicine into Conventional Cancer Care

Edited by Lorenzo Cohen and Maurie Markman. 216 pp., illustrated. Totowa, NJ, Humana Press, 2008. $79.95. ISBN 978-1-58829-869-0.
Reviewed by Donald I. Abrams

Alternative Medicine? A History

By Roberta Bivins. 238 pp., illustrated. New York, Oxford University Press, 2008. $35. ISBN 978-0-19-921887-5.
Reviewed by Teresa L. Schraeder

The Wooification of Medical Journals

I’ll review the reviews, but first let’s consider why their presence in the NEJM is so disturbing. The NEJM is the most widely read and cited medical journal in the world. Among American journals, the top three are usually reckoned to be the NEJM, the Journal of the American Medical Association (JAMA) and, at least for internists, the Annals of Internal Medicine (Ann Int Med). The extent to which each journal has sacrificed its integrity for the promotion of the recent wave of pseudomedicine has varied among the three: the NEJM rarely and, for the most part, unwittingly; JAMA famously in 1998 and occasionally since; and the Ann Int Med repeatedly and embarrassingly, most notably with a series of puff pieces on “CAM” that spanned several years and violated the Annals’ own policies regarding funding disclosures by authors and editors.

To the small extent that the NEJM has previously acknowledged the “CAM” fad, it has been mostly wise in its editorial stewardship. In 1983 it published the best article about pseudomedicine ever to appear in a mainstream journal, which I quoted extensively a couple of weeks ago (if I were King, that article would be reprinted each year or so). The Journal also published, in 1998, the best and most widely cited skeptical editorial on the topic. In 2005 it published a nice piece by our fellow blogger Wally Sampson, who shot holes in the rationale for studying echinacea as a treatment for viral respiratory disease.

It’s true that the Journal has occasionally been fooled, as it and many others were by David Eisenberg’s 1993 survey of the use of “unconventional medicines” by Americans—which was not only inaccurate and wrong in its primary conclusion, but has since been hyped by Eisenberg and the rest of the “CAM” cabal as their major rationale for Making Mischief out of Malarky. More recently, in 2001, Stanford psychiatrist David Spiegel slipped this past the NEJM goalie:

The literature is now evenly divided: 5 of 10 published trials report that psychotherapy prolongs survival, usually moderately, in patients with cancer. The randomized trial we began in the 1970s was based on the hypothesis that psychosocial group therapy would lessen distress in women with breast cancer but would not influence survival. We found, however, an 18-month survival advantage for patients who received group therapy, and this was not accounted for by differences in medical treatment. Since then, four other randomized trials also found that various forms of psychotherapy for patients with cancer were associated with both psychological benefit and longer survival time.

Spiegel didn’t bother to mention that studies purporting to show benefit, mainly his own, had for years been soundly criticized as not worthy of such an interpretation. He also didn’t disclose that his financial and academic fortunes were substantially dependent on readers believing otherwise. Only a year before his NEJM editorial he had published a popular book whose cover states:

Psychiatrist David Spiegel was the first to demonstrate that group support for cancer patients results in significantly enhanced survival times…

In the early 1990s he had made the same claim on the Bill Moyers PBS series, “Healing and the Mind,” a spawning ground for lucrative “CAM” careers. Dr. Spiegel’s desire to keep the public confused about this “mind-body” issue in cancer is still evident on his Stanford Center on Stress and Health website where he claims, albeit in more weaselly words, that

These benefits may lead, in turn, to delayed disease progression and prolonged survival time…

Dr. Spiegel knows, of course, that all adequately powered and methodologically sound trials—including his own attempt to replicate his previous work—have found otherwise. It has long been time to “close the books” on the matter, to borrow a phrase used by former NEJM editor Arnold “Bud” Relman in regard to a more infamous claim. Spiegel doesn’t even need this particular ruse anymore, because he seems to have learned how to milk the udders of fringe and pop-psychiatry, cancer desperation, and “CAM“ quite satisfactorily without it.

The Journal Leaves the Back Door Ajar; “CAM” Slithers In

But back to the New England Journal of Medicine: occasional missteps aside, it has been largely resistant to the “CAM”-wormholes that have recently appeared in the editorial white matter of so many other medical journals. Thus a couple of weeks ago it was particularly disheartening to read, on its pages:

This comprehensive and practical book describes the experiences of the pioneers who established integrative oncology programs at five of the leading National Cancer Institute Comprehensive Cancer Centers in the United States: the University of Texas M.D. Anderson Cancer Center in Houston, the Memorial Sloan-Kettering Cancer Center in New York, the Dana–Farber Cancer Institute in Boston, the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins in Baltimore, and the Mayo Clinic Cancer Center in Rochester, Minnesota. It discusses the challenges of providing therapies that “exist at the interface of science and healing” at institutions with reputations for “providing world class conventional, evidence-based medicine.” The book also includes strategies for meeting these challenges, leaving readers with a feeling of confidence that they now have some of the basic tools for establishing a program at their own medical centers.

That opening paragraph to the first cited review employs much of the misleading language that you, dear readers, are now well-equipped to recognize and translate. There is sloganeering, question-begging, baiting and switching, and more: “Pioneers”? “The interface of science and healing”? (healing?) “The challenges of providing therapies [at places that ought to know better]“? (therapies?) Nowhere in the subsequent text is there an answer to the implicit question that a rational person would ask, having read that paragraph: why would anyone want to “establish such a program?” Instead there is more question-begging, data-begging, and outright avoidance of pertinent issues:

Many patients with cancer want to improve their chances for successful outcomes and decrease the chances of treatment-related side effects by incorporating complementary therapeutic approaches into their overall treatment plans.

Integrative oncology is not about the use of specific unconventional approaches to treatment; it is about an overall approach to treatment of the whole patient.

How does one go about credentialing acupuncturists at a major academic cancer center?

What is the best approach for educating medical staff about the potential benefits of various complementary interventions?

Is Reiki within the scope of practice of registered nurses in your state?

The Dana–Farber team has contributed a particularly helpful chapter that includes valuable tables as well as copies of policies, procedures, and competency evaluation forms, a template for an acupuncture referral letter, and an outline of how acupuncturists document their interventions in electronic medical records.

The chapter contributed by the team from Johns Hopkins includes practical tables on indications and contraindications for acupuncture and massage for the oncology patient, clearly outlining who may benefit and how best to administer these treatments safely.

These leaders in the field all recognize that the way to ensure that these methods become fully integrated into cancer care is to provide the data that will allow even the most conventional oncologists to appreciate their value.

This book is an invaluable resource for all involved in the care of patients with cancer. Those interested in developing an integrative oncology program, or any integrative medicine services, at their institutions will find the book especially useful.

It may well inspire others to follow the lead of these courageous pioneer clinician–scientists in their attempts to maximize healing for people living with and beyond cancer.

“Courageous,” indeed. The first paragraph of the second book review is slightly more promising:

Whether acupuncture from China, Ayurvedic therapies from India, or homeopathy in Europe, in her scholarly book, Roberta Bivins presents the belief systems that gave rise to such ancient practices and then follows their subsequent problematic global voyages to other cultures. Neither an allopathic doctor nor an alternative practitioner, Bivins provides readers with a social examination of these “exotic” techniques, from moxabustion to mesmerism, and explains how each was introduced (and then studied, simulated, ridiculed, or rejected) by Western physicians in Europe and the United States. The nearly four-century transcontinental propagation was not always easy — especially when corresponding belief systems could not be transported along with the therapeutic techniques.

Other than the misnomer “allopathic” and the question-begging “therapeutic,” that paragraph might refer to a perfectly reasonable treatise on pre-scientific and non-scientific health claims. Upon reading it and noticing the question mark after “Alternative Medicine” in the title, I allowed myself a glimmer of hope that the book and its review might rise to the Journal‘s usual, scholarly standards. I shouldn’t have bothered:

The translation of these principles and techniques from East to West paralleled the interaction of the cultures themselves, with all the inherent stereotyping, superstitions, and feelings of racial and cultural superiority. Ultimately, despite British imperialism or the medical profession’s turf wars, it was often the realities of — and the lack of therapies for — epidemics of cholera and the plague, or ailments such as gout, that encouraged quick investigation and resulted in rejection or eventual co-optation of the unfamiliar treatments. Of note, the authorities investigating and discounting alternative therapies were also often “borrowing” the practices for reintroduction as their own. One example was moxabustion, a therapy that uses heat and was apparently effective in the treatment of gout.

During the 18th and 19th centuries, the Western medical establishment was looking with a critical eye at the use of Chinese herbs and the practice of homeopathy while practicing what it knew as the best standards of care — cupping and bleeding. Some ancient practices were later “discovered” in the West. Centuries before Edward Jenner determined that mild cowpox exposure conferred immunity to smallpox, Asians practiced variolation— the controlled exposure to a carefully selected mild case of smallpox in one person to produce immunity in another. This same practice is followed today by some parents, who bring their unimmunized children to chicken pox or measles parties.

Early remedies paved the way for later advances. Acupuncture was not readily adopted by Western doctors, but Bivins speculates that acupuncture helped to familiarize them with needles, domesticating needles for later use in vaccines, drug delivery, and the drawing of blood. There are important lessons in this book for practicing physicians. For example, techniques such as homeopathy may have become popular not because of consistent efficacy but because the patients appreciated attentive clinicians and were attracted to the treatment’s benign nature and affordability.

The Western physician, past and present, is made out to be mostly predatory and misguided. Bivins questions why researchers continue to assess treatments from other cultures in a Western framework. Admittedly, we do not have the technology to measure qi or to visualize prana (which of course does not disprove their existence), but we do have the tools to objectively evaluate clinical interventions. With 60% of U.S. medical schools now offering some instruction in alternative medicine, and the commitment to research being made by the National Institutes of Health’s National Center for Complementary and Alternative Medicine, there is an effort under way to evaluate practices that may hold promise and bring them into our evidence-based world.

Bivins’s book is a work of scholarship filled with thoughtful discussion, but it is largely devoid of colorful or memorable characters, a clear timeline or plot, or clinical discussions— all of which would have made the book more appealing. Bivins does ask one provocative question, illustrated in part by the use of a question mark in the book’s title: Why do we continue to use the word “alternative” when the popularity and complementary integration of some of these therapies, especially for the treatment of chronic conditions, continues to increase? There are now more patient visits to alternative medical practitioners than to primary care physicians in the United States.

In the end, this book is about Western attitudes toward the non-Western world. It is a macroscopic analysis rich with philosophical reflection and historical observation that exposes the difficulty of exporting such therapies outside their original cultures and belief structures.

Wow.

I groan (again) as I ponder the task of trying to make sense of those words, but that is the commitment I have made to you, dear readers. We seem to be told that British Imperialism notwithstanding, “Principles and Techniques from [the] East” were found by Westerners to be effective therapies for cholera and the plague. Hmmm; I hadn’t heard that before. Next, we seem expected to share a sense of enlightened irony that during the 18th and 19th centuries two pre-scientific practices, Chinese herbal medicine and homeopathy, competed with two other pre-scientific practices, cupping and bleeding. I don’t know about you, but that strikes me as a mundane historical finding. I’m as amused as the next guy when I see an advertisement warning against “fake psychics,” but I’m smart enough to know that it doesn’t follow that there are real ones.

I’m also educated enough to know that variolation is not the same as vaccination and that even if it were, or even if vaccination had been discovered in Asia, so what? The issue here is not the plausible; it’s the implausible, such as the notion that acupuncture “domesticat[ed] (!) needles for later use…” or that in the absence of homeopathy and other treatments that lack “consistent efficacy,” it would likely never occur to today’s physicians that people prefer their doctors to be attentive and their health care to be safe and inexpensive.

In a rare, succinct passage, the next paragraph reveals the real agenda of the book:

The Western physician, past and present, is made out to be mostly predatory and misguided.

Why didn’t the reviewer tell us that in the first place? For readers who may be new to SBM, don’t get me wrong: Some Western physicians undoubtedly are “predatory and misguided,” but this book ain’t complaining about them. Rejecting implausible health claims is not a sign of being predatory and misguided. Quite the contrary: promoting such claims is pathognomonic of those traits. And what does reviewer Teresa Schraeder, a physician, think of the book’s agenda? We can’t tell in this paragraph because the rest of it is unrelated, but later she gives us strong hints.

Now: “Bivins questions why researchers continue to assess treatments from other cultures in a Western framework.” So much for Ms. Bivins’ understanding of science, but what of Dr. Schraeder’s?

Admittedly, we do not have the technology to measure qi or to visualize prana (which of course does not disprove their existence)… 

Oh my. Dr. Schraeder is the Graduate Medical Education Editor of the NEJM. The gaffs in that phrase make her subsequent, inflated estimate of “tools to objectively evaluate [highly implausible] clinical interventions” and her naive endorsements of the NCCAM and of “instruction in alternative medicine” offered in medical schools seem almost, well, commonplace. Was it possible that she would redeem herself when she wrote…

Bivins’s book is a work of scholarship filled with thoughtful discussion, but…”   ?

But what? But it lacks a pertinent discussion of science and modern medicine? But it suffers from misapplied cultural relativism? C’mon Terry, you’re this close!

…but it is largely devoid of colorful or memorable characters, a clear timeline or plot, or clinical discussions…

Oops (sigh). The book is undoubtedly filled with fictitious statements, but am I alone in having assumed, prior to reading that sentence, that it is not a work of fiction in the formal sense? We do get to find out why the question mark appears after “Alternative Medicine” in the book’s title, but by now it’s anticlimactic: rather than calling attention to the misnomer, its purpose is to suggest that “alternative” is no longer needed because

the popularity and complementary integration of some of these therapies, especially for the treatment of chronic conditions, continues to increase[.] There are now more patient visits to alternative medical practitioners than to primary care physicians in the United States.

If there remains any doubt that reviewer Schraeder agrees with author Bivins that it is popularity but not rational evaluation that determines the validity of “alternative” claims, the final quoted statement appears to put it to rest:

In the end, this book is about Western attitudes toward the non-Western world. It is a macroscopic analysis rich with philosophical reflection and historical observation that exposes the difficulty of exporting such therapies outside their original cultures and belief structures.

And there you have it. “In the end,” it isn’t about science or rational evaluations or astrologic/militaristic/demonologic/meteorologic or “constitutional” metaphors, or the occult or sympathetic magic or psi or any other magical thinking, or conjuring or ideomotor action or demand characteristics or cognitive dissonance or any of that other “Western” BS. It’s all about The Man watching his own back. Sheeit, I knew that in college.

Let history record that versus the New England Journal of Medicine on July 31, 2008, it was Game, Set and Match to Pseudomedicine.

Please, Dr. Schwartz, Say it Ain’t So!

I wish I could be consoled by the knowledge that these book reviews are, well, just book reviews. They’re kind of at the back of the journal, and a lotta people don’t bother to read them. There are precedents in other journals for whacky stuff finding its way into the book review section, stuff that would never (but I’m not so sure anymore) make it to the editorials or the original papers. JAMA published a book review a few years ago that openly asserted that psychokinesis ought to be useful in clinical medicine (the reviewer called it “the scientific evidence of the effects of nonlocal mind”). I still can’t believe that the big guns on the editorial staff were aware of it, but maybe I’m the naive one now.

Still, the NEJM should be different. The book review editor is Robert Schwartz, who knows better. He wrote an editorial a couple of years ago decrying the teaching of “intelligent design” as “pseudoscience by mandate,” and worrying that it might make its way into medical schools:

Indeed, first and foremost, intelligent design should concern physicians because the debate influences education at all levels. Now that Bill Frist, the Senate majority leader and a graduate of Harvard Medical School, has come out in favor of the teaching of intelligent design, medical students may soon be learning that only a hidden hand could be responsible for the complexities of oxidative metabolism in mitochondria. (An intelligent student might ask why the designer made mitochondria in the first place.) Moreover, the confusion between faith and science at the highest levels of public education can hardly be an asset to the pool of applicants to medical schools and graduate schools in the sciences.

What would it mean to take intelligent design seriously at the medical school level? Its proponents tell us that gaps in our knowledge of how living organisms evolved vitiate the theory of evolution. Might we conclude, then, that the cancer cell and its evolution are so complex that a creative designer must be the cause of cancer? But if the designer created cancer, is it against the hidden hand’s will to find a cure for cancer? Is it in accord with the plan of the intelligent designer to receive a treatment for cancer? After all, a Jehovah’s Witness would rather die than receive a blood transfusion. Yet today more than ever, the profession needs physicians who can channel scientific discoveries to the sick. What effect will pseudoscience-by-fiat have on medical progress?

If we accept the premise that it is not in the long-term interest of medicine to disguise a faith-based belief as a scientific discipline and indoctrinate future physicians and scientists in a creed that thwarts the science of medicine, what can physicians do now? It seems to me that leaders of professional societies and prominent academicians should start speaking up…Engaging in a public debate about intelligent design is probably not a good idea; any debate about faith and belief will surely end inconclusively. More desirable are education and acting to protect the profession and the public from pseudoscience.

I wrote the NEJM a short letter after that piece, making the point that although I agreed with everything Dr. Schwartz had written, pseudoscience has already insinuated itself into medical schools and other medical institutions to a far greater extent than most people realize, in the form of “CAM.” (Note to Dr. Schwartz, if you happen to read this: in case you had any doubts then, please read the reviews under review here). I must admit that I was surprised when my letter was refused for publication. I had figured that it would be a slam-dunk after an article such as Schwartz’s, but as far as I know there were no published letters pertaining to his article at all.

Kinda makes you think, as Bob Dylan might say. Later I met Dr. Schwartz rather by accident, and after each of us had figured out who the other was we had some good laughs about the intellectual matter. I’m afraid you’ll have to accept that it wasn’t the proper setting to raise questions about in-house politics, but as far as science and pseudoscience are concerned, he gets it. I can only imagine that he was away, or too busy to read them himself, or whatever, when the two reviews discussed here slipped through.

Should a Reviewer Disclose that He’s Palsy-Walsy with the Book’s Author? Or, a Preview of Next Week

You might have guessed that I have not read either of the books that are the subjects of the cited reviews; this post is about the reviews, not about the books. Nevertheless, the astute reader might reasonably wonder whether Donald Abrams, the reviewer of the “integrative oncology” book, can be forgiven for some of his presumptions as long as the book itself supports them. Thus there is a need for us to learn something about “the data that will allow even the most conventional oncologists to appreciate their value.” Fortunately, there are ways to do this that don’t involve shelling out $80 or, in my case, making a cumbersome and parkless trip to the venerable Countway Library of Medicine. The table of contents, the names of the contributing authors, and the introduction are available on Amazon.com. The review itself provides another clue:

…the contributors to this book are all deeply involved and committed to educating their colleagues about the advances in the field; three of them have served as presidents of the Society for Integrative Oncology.

If you go to that Society’s website, you’ll indeed find that Lorenzo Cohen, one of the book’s editors, is the Society’s president. You’ll also find there, but not in the NEJM, that Donald Abrams, the book’s reviewer, is the Society’s Secretary/Treasurer. Is it possible that they know each other? ;-)

And finally:

Ode to the New England Journal of Medicine: a Reader’s Lament

Hark, O Journal of New England!

From whose Warrens you raised our Holmes

 Even before we were Bud’s!

Of late thou seemest to be Wandr’zin’;

Where is thy Guardian Angell now?

If only we Kassirer!

If not, may the Schwartz be with you!

Posted in: Book & movie reviews, Cancer, Medical Academia

Leave a Comment (7) ↓

7 thoughts on “The New England Journal of Medicine Disappoints

  1. Harriet Hall says:

    When I read these two book reviews in NEJM I almost threw up. Thanks for your thorough analysis. I hope you sent a copy to the editors of NEJM.

  2. James Fox says:

    As a person who was recently diagnosed with cancer and who’s put a tremendous amount of effort into researching the best and most current scientific treatment practice, and in finding the most competent and available medical providers, I’m not just bothered by these journal articles I’m disgusted. People will no doubt be encouraged to seek out ineffective and dangerous care, all the while delaying more effective and science based treatments, leading to unnecessary progressions of their diseases and even premature death. Perhaps the authors forgot how important their words really are and can be, given the level of authority and preeminence these journals convey, especially to the general public.

  3. overshoot says:

    Many patients with cancer want to improve their chances for successful outcomes and decrease the chances of treatment-related side effects by incorporating complementary therapeutic approaches into their overall treatment plans.

    And presumably the rest of us will have no say in the matter; if there’s a witch doctor as part of the surgical team, it’ll all go on the bill and the first we’ll learn of it is when we are presented with a demand for payment of services.

  4. mandydax says:

    *sigh* I learned about logical fallacies in high school, mostly in regard to advertising, and it baffles me that supposedly critic thinkers should fall for these arguments. I was literally agape at these statements. Dr. Schraeder, would you like some more more argumentum ad populi with your appeals to tradition and negative proofs?

  5. Joybobington says:

    “a template for an acupuncture referral letter”

    What in the unholy hell?!

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