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 Anthony Komoroff has pointed out that many of your comments about the InteliHealth treatment of CAM are now grossly out of date as the material inherited from another provider has been reviewed by HMS faculty and modified.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.
Archive for Medical Academia
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…)
HMS Puts the Messenger in its Crosshairs
When, during the fall and winter of 2001-02 I first approached Dean Daniel Federman of the Harvard Medical School (HMS) with evidence that the HMS “CAM” program was promoting pseudomedicine, I gave him some materials that I thought would be adequate to make the case: ‘CAM’ Director David Eisenberg’s dubious funding sources and his failure to disclose them to the Massachusetts Special Commission; the website of the Caregroup/Harvard Medical School Center for Alternative Medicine Research and Education (CAMRE), which urged anonymous websurfers to “consult your local telephone yellow pages” for ‘naturopathic physicians’ and other quacks; the presence on the ultra-PPO American Association for Health Freedom (AAHF) Advisory Board of attorney Michael H. Cohen, the Harvard CAMRE’s “Director of Legal Programs” (at the time, Dr. Federman agreed with me that the mere existence of such a position was curious, if the CAMRE’s purpose was “research and education”); that Dr. Eisenberg and Atty Cohen had contributed to a report to the Massachusetts State Legislature recommending a formal state imprimatur for the practice of pseudomedicine; and other embarrassing findings. A bit later, in March 2002, I sent him a draft of the essay that I posted in Parts I and II of this series.
That material proved not to be adequate, for on March 20, 2002, Dr. Federman sent me the following letter:
I ready to undertake a formal review of the Harvard Medical School’s Division of Research and Education in Complementary and Alternative Medicine, and of its leadership to investigate the charges outlined in your letter of November 4, 2001, subsequent emails, and our meeting of January 22, 2002 in my office. I have read almost all of the voluminous literature you sent me and am writing to ask you to assist our efforts. Specifically, I am asking you to prepare a one to three page summary of the specific portions of the material you sent me that you consider erroneous, duplicitous, misleading, or fraudulent.* I do not feel I should summarize your views. Please be specific and give sources, where you can, in support of your statements.
I am committed to achieving a careful and balanced review of the issues you raise.
Daniel E. Federman, M.D.
* [These are terms that I had used in my communications with Dr. Federman; the only one from which I backed away, after he reacted with considerable alarm, was “fraudulent.”]
That was the first real suggestion that the fix was in. The pertinent literature that I’d sent Dr. Federman did not consist of “my views” or even my words. It consisted of statements copied from CAMRE publications and other public sources. Why did Dr. Federman now seem to be framing the issue as a matter of (my) opinion? Why weren’t the points that I’d already presented and documented (they were specific and I gave sources) sufficient to trigger an independent, formal review? What about the summary that I’d already written in the form of a letter to Harvard Magazine, which Dr. Federman had also read? No matter: I was still confident that he would do the right thing when he saw the totality of the evidence, abundantly and overwhelmingly supporting my contention that the CAMRE and other HMS affiliates were promoting pseudomedicine—dangerously, unethically, and in contrast to their stated purpose.
It was then that I resolved to write the essays that I posted in Parts I, II and III of this series.‡ I also prepared the summary that Dr. Federman had requested, which is reprinted below. In June, 2002, I sent these together with this letter:
In Parts I and II of this series* we saw that from 2000 to 2002, key members of the Harvard Medical School “CAM” program, including the Director, had promoted quackery to the legislature of the Commonwealth of Massachusetts. We also saw other explicit or tacit promotions by Harvard institutions and professors, and embarrassing examples of such promotions on InteliHealth, a consumer health website ostensibly committed to “providing credible information from the most trusted sources, including Harvard Medical School….”
Those points were made in an essay that I sent in the spring of 2002 to Daniel Federman, the Senior Dean for Alumni Relations and Clinical Teaching at Harvard Medical School (HMS). I also sent Dr. Federman a treatise on homeopathy, including several examples of credulous Harvard professors and misrepresentations aimed at students, patients, and the public. Much of the content of that treatise has been covered by the series on homeopathy† with which I began my stint here on SBM, so here I’ll post only the parts relevant to promotions by academic physicians, including those at Harvard. There is a bit of redundancy involving InteliHealth, but please bear with me if you’ve made it this far; the discussion will be meatier than the short summary in Part II.
In Part I of this series† we saw that in 2001 Dr. David Eisenberg, the Director of the Harvard Medical School Center for Alternative Medicine Research and Education (CAMRE), and Atty Michael Cohen, the CAMRE’s Director of Legal Programs, had contributed to a report commissioned by the Commonwealth of Massachusetts that would, if accepted as valid by the legislature, provide state protection for a group of quacks to practice ‘medicine.’ We also saw that Dr. Eisenberg had accepted funds from this very group, without having disclosed that information to the relevant state Commission. We saw examples of the quackery that the group espouses, including methods advocated by Thomas Kruzel, the Chief Medical Officer of the school that had contributed money to Dr. Eisenberg’s Harvard “Complementary and Integrative Medicine” course.
We continue now with the essay that I sent in the spring of 2002 to Dr. Dan Federman, the Senior Dean for Alumni Relations and Clinical Teaching at Harvard Medical School (HMS). As before, I’ve provided hyperlinks to many of the citations that I included in my original essay; some, however, are no longer available.
The American Association of Health Freedom
Kruzel and Harvard’s Michael Cohen are listed as key figures—Kruzel the Secretary, Mr. Cohen the only lawyer on the Advisory Board—in a lobbying organization known as the American Association of Health Freedom (AAHF). Formerly known as the American Preventive Medical Association (APMA), it was founded by Julian Whitaker, MD, a former orthopedic surgical resident who decided that “natural therapies” offered a more lucrative career path. Its purpose, as suggested by the standard euphemism, is to convince government of the validity of dubious medical claims through political influence rather than science. The AAHF lobbies heavily for the passage of the annually defeated federal “Access to Medical Treatment” act, which would allow quacks to prey freely on unwary consumers.
Several years ago I stumbled upon disturbing information regarding my alma mater, the Harvard Medical School (HMS).† Its professed commitment to investigate implausible medical claims had somehow metamorphosed into the advocacy of such claims. I’ve previously mentioned some of this on SBM (here and here). A couple of pertinent essays appeared in the public domain in 2002 and 2003, but the full story was much more involved than those pieces revealed. In the wake of recent posts on SBM about medical schools exposing students to uncritical portrayals of pseudomedicine, it seems appropriate to tell more of it. I’ve also decided to name names, which is something that I would have been reticent to do a few years ago. The basis for that decision will become clear over the next few posts, I trust. This topic will require at least three posts.
My discovery that HMS had begun promoting pseudoscientific medical claims was occasioned by my experience on the Massachusetts Special Commission on Complementary and Alternative Medical Practitioners, which met from the fall of 2001 to the winter of 2003. Another member of that commission was David Eisenberg, the Director of the Harvard Medical School Center for Alternative Medicine Research and Education (CAMRE) and of the new Osher Center for Complementary and Integrative Medical Therapies. Dr. Eisenberg is best known for his 1993 article reporting the use of ‘unconventional therapies’ by Americans. He had been appointed to the commission by the MA Commissioner of Public Health at the time, Dr. Howard Koh–whom President Obama has recently nominated to be Assistant Secretary of HHS. I assumed then, and still do, that Dr. Koh presumed Dr. Eisenberg to be an objective expert on “CAM,” since that was the persona presented by HMS and by Dr. Eisenberg himself. I had my doubts, but before then I’d not bothered to look into the matter.
It was during commission meetings, when I had the opportunity to hear what Dr. Eisenberg and his surrogate had to say or not to say and when I examined some of their writings and funding sources, that I began to realize how far his project was deviating from what I imagined to be the agenda of HMS. Some of what I saw amounted to frank dishonesty: failure to disclose obvious conflicts of interest to the Commission, for example. I also discovered public promotions of dubious “CAM” practices and practitioners by the CAMRE, in spite of its formal purpose being that of investigating “CAM” practices in an attempt to find out if any might be useful. I was concerned enough to look at other “CAM” information offered in the name of Harvard, and I found more worrisome examples.
I also attended the Feb., 2001 Harvard Complementary and Integrative Medicine Course, directed by Dr. Eisenberg (here is a link to the similar 2002 course brochure). A few of the talks were reasonable, if banal. I did my best to give them the benefit of the doubt, because I still could not accept that HMS would seriously consider homeopathy, ‘life-force,’ and ‘subluxations’ as being worthy of study, much less advocacy. After attending a semi-rigorous talk on raw herbs as medicines (the presenter discussed some studies but not the looming question of why whole herbs might be preferable to purified molecules), I ran into Eisenberg and did my best to be polite and encouraging. I shouldn’t have, because most of the content of the course was misleading and pseudoscientific. Overall, its tone was more like a political rally or a religious revival than a scientific conference.
At that course I ran into Russell Phillips, who had been in my group of interns at the Beth Israel Hospital (Boston) in 1979. I’d seen him around from time to time over the years, and I’d known that he’d stayed on at the BI after his residency. I was surprised, however, to learn that he was now the Director of the Harvard CAMRE Fellowship program. I was even more surprised to learn, during a short conversation with him, that he was innocent of the chiropractic ‘subluxation theory’ and that he’d never heard of Quackwatch. It seemed to me that there was either a surprising naivete among this crowd or an attempt by some to shun unpleasant information.
Here at Science-Based Medicine we’ve been getting a lot of letters from medical students. This is a good thing and a bad thing. I’m glad people see us a a resource for SBM, but I’m unhappy that medical students: 1) need us; 2) don’t have someone to approach on campus. Let’s explore some of the more subtle ways cult medical practices infiltrate medical education.
In order to give all of their students experience in outpatient medicine, most med schools must reach out to the community. Sure, some med schools have big enough clinics to support an experience for all of their students, but that’s the minority. For their internal medicine, pediatrics, and family medicine rotations, med students often spend time at private doctors’ offices. These offices are minimally vetted, and I’d venture to guess that the vetting does not include checking for non-standard practices. In fact, schools are so desperate for spots, that almost any office will do. It’s good for students to see how medicine is practiced in the “real world” but that real world often involves cult medicine practices. Along the same lines, many practitioners are not up to date on the most recent best practices. I remember a family doc I worked with who used to give huge doses of intramuscular steroids to people for seasonal allergies. This isn’t the best idea, but I was a student. Who was I to tell him how to practice medicine?
We don’t police our colleagues very effectively—we have surrendered that duty largely to the courts. However, if doctors want a medical school affiliation, it seems a small price to allow the school to come in and see if the office practices medicine according to the standard of care. In addition to checking for the most minimal quality standards, it would rule out docs who are offering voodoo in place of medicine.
Early in the history of this blog, I wrote a rather long post expressing my dismay at the infiltration of unscientific “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) modalities into American medical schools. In it, I listed the medical schools that had embraced pseudoscience through having started a CAM/IM program (a list desperately in need of an update). Moreover, we have also complained vociferously here about a clear effort on the part of advocates of faith-based medicine to infiltrate bastions of science-based medicine and to piggyback their agenda onto President Obama’s health care reform initiative in a clear political strategy to slip CAM/IM into any health care reform legislation as a form of “preventative medicine.” It’s all part of a multi-pronged strategy to claim popular and legal legitimacy in the absence of scientific legitimacy. At one point I even despaired because of the apparent success of half physician, half CAM huckster Dr. Andrew Weil at developing a CAM/IM curriculum that would be part of the mandatory training program in several family medicine residencies, while the rest of us watch Senator Tom Harkin try to promote pseudoscience in the halls of the Senate.
However, since one of our newest co-bloggers, medical student Tim Kreider, arrived, I’ve come to appreciate that medical schools and medical school curriculae are ground zero in the battle for science- and evidence-based medicine. Besides the infiltration of non-science-based modalities into the standard curriculum, another technique for making medical students believe that woo is equal to science is the student “campus CAM group” that invites, for example, homeopaths and naturopaths to give talks to medical students, too many of whom are too timid to challenge them on their pseudoscience. However, a reader of a “friend” of mine wrote me an e-mail that truly appalled me. In fact, it appalled not just me, but all of my co-bloggers who read it. It’s from a medical student in an American medical school. It’s not Harvard or a huge famous medical school. However, it is in medical schools like this one where the vast majority of medical students are trained in this country. If the infiltration of CAM/IM into medical schools continues in this way, we’ll have more than just “integrating” woo into the medical school curriculum from day one. We’ll have more tales like this; eventually, no one will find such tales unusual or even unacceptable anymore. The shruggies will no longer even shrug anymore. Such clinics will become simply the way medical students are educated. The following e-mail is de-identified, and I’ve edited it a bit to make as sure as I can that it is not traceable:
When beginning a discussion of a controversial topic I like to establish the common ground upon which most or all people can agree. Everyone seems to agree that real conflicts of interest in medical research and practice is a bad thing and steps should be taken to minimize, eliminate, and illuminate any such conflicts. The controversy revolves around what constitutes a real conflict of interest.
There is broad agreement that researchers should not have a personal financial stake in the outcome of their own research – they should not make more money if their research is positive than if it’s negative. That creates a clear and powerful bias. There is also now broad agreement and adoption of standards that speakers, authors, and researchers should disclose any potential conflicts of interest – primarily the source of their funding. If someone is being paid by a drug company to say that their drug is effective for a particular disease, they should disclose that up front.
These same standard are now being applied to IRBs – institutional review boards, and that seems apprpriate. Every institution that does biomedical research must have an IRB, which is a committee of appropriate professionals (and there are rules as to the IRB’s constitution) that review all human research proposals to make sure they meet ethical guidelines and that subjects are adequately protected. This is a good system that generally works.
The latest event sponsored by “integrative medicine” proponents on my medical school campus featured the naturopath “Dr.” PB, a 2003 graduate and valedictorian from Bastyr University. Advertisements all over campus billed the lecture as “Stress, nutrition, and the GI tract,” which seemed innocuous enough. However, the lecture title as written on PB’s slide show was “Naturopathic apologetics for treating the gut.” He explained “treating the gut” to mean that for a wide variety of symptoms the naturopath’s diagnosis inevitibly focuses on the intestine and interventions nearly always involve dietary changes or supplements. Apparently some critics find this preoccupation to be excessive; hence “apologetics,” a word that connotes rational defense of articles of faith. This word choice was appropriate, as the lecturer wove snippets of basic physiology, but never any direct evidence, into a just-so story about how nearly all disease is caused by the modern lifestyle and can be ameliorate with dietary intervention.