Every so often, the reality of trying to maintain a career in science-based medicine interferes with the fun that is writing for this blog. Basically, what happened is that I spent the entire weekend working on three different grant applications and, by the time Sunday night rolled around, I was too exhausted to write what I had originally planned on writing. Fortunately, one advantage of having been blogging so long and also having blogged under a pseudonym over at my not-so-super-secret other blog is that there’s a lot of material which is pretty damned good, if I do say so myself, that I can draw on for just these situations. Even better, it’s old enough that it’s unlikely that most of you have actually come across it before, which makes it new to you (well, at least most of you). As a special bonus, the jumping off point was a post by an occasional contributor to this blog, Peter Lipson. Actually, I wish Peter would contribute more regularly, but he’s too busy moving on to bigger things at Forbes.
This time around, I’m half-recycling, half-revising a post that was a bit more navel-gazing than usual. However, as the only surgeon on SBM I think it’s actually useful every now and then to discuss the trials and tribulations of practicing science-based surgery. It began when Peter wrote an excellent meditation on a topic that’s always been a difficult issue for me to face as a surgeon, namely how one balances confidence in one’s ability with humility in the face of disease and uncertain science. He started with a spot-on observation:
The practice of medicine requires a careful mix of humility and confidence. Finding this balance is very tricky, as humility can become halting indecision and confidence can become reckless arrogance. Teaching these traits is a combination of drawing out a young doctor’s natural strengths, tamping down their weaknesses, and tossing in some didactic knowledge.
For many years I have been using Continuing Medical Education (CME) programs offered by the American Academy of Family Physicians (AAFP). The FP Essentials program consists of a monthly monograph with a post-test that can be submitted electronically for 5 hours of CME credit. Over a 9-year cycle, a complete family medicine curriculum is covered to prepare participants for the re-certification board exams. Some examples of typical subjects are skin cancer, hand and wrist injuries, valvular heart disease, and care of the newborn. I rely on these programs to learn, review, and keep up-to-date in my specialty. Imagine my dismay when I opened the latest package to find a monograph on Integrative Medicine.
First it was called various names like folk medicine, quackery, and unproven/untested treatments, then all of those (the less rational right along with the more rational) were lumped together under the umbrella term “Alternative Medicine,” then it became “Complementary and Alternative Medicine” (CAM), and now it has been re-branded as “Integrative Medicine.” The term is designed to make unscientific treatments seem more acceptable to science-based doctors. “Integrative Medicine” is a marketing term, not a meaningful scientific category. It is a euphemism for combining Complementary and Alternative Medicine (CAM) with mainstream medical practice, unproven with proven, magic with science. It has been critiqued many times on this blog. We have stressed that there is only one medicine, and that when a treatment is proven to work by good evidence, it is just “medicine.” When the evidence for a CAM treatment is not good, it essentially amounts to experimental treatments and/or comfort measures. Worse, sometimes CAM even persists in using treatments that have been proven not to work or that are totally implausible, like therapeutic touch or homeopathy. (more…)
Three weeks ago, I gave a talk to the National Capital Area Skeptics at the National Science Foundation in Arlington, VA. The topic was one near and dear to my heart, namely quackademic medicine.
I was informed the other day that the video had finally been posted. Unfortunately, there were some problems with the sound in a couple of places, which our intrepid NCAS video editor did his best to fix. Overall, however, the sound quality seems decent. The video even includes the Q&A session. In case you’re interested, the guy who asks the question about mercury in vaccines and autism is Paul Offit’s very own stalkerJake Crosby. I feel honored to think that Jake now apparently lumps me in the same category as Paul Offit, whom I admire greatly. Enjoy.
I thought I’d take advantage of my prerogative as managing editor of this blog to do a quick bit of blatant self-promotion. I will be in the Washington, DC area later this week, and while I’m there to attend the Society of Surgical Oncology Annual Cancer Symposium, I’ll also be taking advantage to do a little side trip to give a talk for the National Capital Area Skeptics. The talk will take place at the National Science Foundation in Arlington, VA on Saturday, March 9, 2013 at 1 PM. So if you’re in the DC area and want to hear me pontificate about quackademic medicine (and, really, what reader of this blog wouldn’t want to?), mosey on over on Saturday. Full details can be found here.
We can’t stress often enough that anecdotes are not reliable evidence; but on the other hand, patient stories can serve a valuable purpose in medical education. Hearing how a disease affected an individual patient is more powerful than reading a list of symptoms in a textbook and is far more likely to fix the disease in the student’s memory. When I think of Parkinson’s disease, the first thing that comes to mind is my first patient with Parkinson’s and how he responded to levodopa; and the first thing that may come to many people’s minds is Michael J. Fox. Of course, we must realize that they may not be typical examples; but putting a face to a diagnosis serves as a memory aid and a hook to hang the rest of our knowledge on.
In his new book, The Power of Patient Stories: Learning Moments in Medicine, Paul F. Griner, MD relates more than 50 stories that distill the wisdom he has developed over a 58-year career of practicing medicine and teaching young doctors. He describes them as “stories that provided a learning moment for me.” It’s interesting to see how much medicine has changed over his professional lifetime and yet how cases from the 50s and 60s are still highly relevant. Ethical dilemmas and lessons about medical practice come alive under his pen. Each story is followed by incisive questions and exercises that engage the reader and challenge him to think about the issues. (more…)
There’s a saying in medicine that we frequently hear when a newer, more effective therapy supplants an older therapy or an existing therapy is shown not to be as efficacious as was once thought, and it has to do about how long it takes for the use of that therapy to decline. The saying basically says that the therapy won’t die out until the current generation of established physicians retire and are replaced by the new generation coming up through medical schools. From my perspective, it’s a bit of an exaggeration, because in the mere 13 years that I’ve been a real doctor (i.e., an attending physician) our practices in breast cancer surgery has changed markedly. Although certain core principles of breast cancer care remain the same, there have been major changes in terms of how we deal with the axillary lymph nodes, our use of hormone therapy and chemotherapy, and our very understanding of the different subtypes of breast cancer. Of course, I have spent my entire career as faculty at two different NCI-designated comprehensive cancer centers; so my experience is not representative of that of most physicians, particularly given that I’m super subspecialized. It’s generally expected that if you’re faculty in an academic medical center you will be at the very least up to date, if not beyond at the cutting edge.
Even so, there is some truth to the observation that it takes the rise of a new generation of physicians to force out certain old ideas, which means that how we train our medical students is of utmost importance. Unfortunately, these days, it is medical students who have become a major force for promoting the “integration” of quackery into medicine (which these days is known as, appropriately enough in a way unintended by its proponents, “integrative medicine”). No, I’m not saying that all or even most medical students are prone to the blandishments of quackademic medicine, but rather that there is a large enough contingent of medical students who have gone beyond being shruggies to become activists for unscientific medicine. There are CAM clubs, CAM interest groups, and student-driven CAM electives.
There are certain topics in Science-Based Medicine (or, in this case, considering the difference between SBM and quackery) that keep recurring over and over. One of these, which is of particular interest to me because I am a cancer surgeon specializing in breast cancer, is the issue of alternative medicine use for cancer therapy. Yesterday, I posted a link to an interview that I did for Uprising Radio that aired on KPFK 90.7 Los Angeles. My original intent was to do a followup post about how that interview came about and to discuss the Gerson therapy, a particularly pernicious and persistent form of quackery. However, it occurred to me as I began to write the article that it would be better to wait a week. The reason is that part of how this interview came about involved three movies, one of which I’ve seen and reviewed before, two of which I have not. In other words, there appears to be a concerted effort to promote the Gerson therapy more than ever before, and it seems to be bearing fruit. In order to give you, our readers, the best discussion possible, I felt it was essential to watch the other two movies. So discussion of the Gerson protocol will have to wait a week or two.
In the meantime, there’s something else that’s been eating me. Whether it’s confirmation bias or something else, whenever something’s been bugging me it’s usually not long before I find a paper or online source to discuss it. In this case, it’s the issue of why scientific studies are reported so badly in the press. It’s a common theme, one that’s popped upon SBM time and time again. Why are medical and scientific studies reported so badly in the lay press? Some would argue that it has something to do with the decline of old-fashioned dead tree media. With content all moving online and newspapers, magazines, and other media are struggling to find a way to provide content (which Internet users have come to expect to be free online) and still make a profit. The result has been the decline of specialized journalists, such as science and medical writers. That’s too easy of an answer, though. As is usually the case, things are a bit more complicated. More importantly, we in academia need to take our share of the blame. A few months ago, Lisa Schwartz and colleagues (the same Lisa Schwartz who with Steven Woloshin at Dartmouth University co-authored an editorial criticizing the Susan G. Komen Foundation for having used an inappropriate measure in one of its ads) actually attempted to look at how much we as an academic community might be responsible for bad reporting of new scientific findings by examining the relationship between the quality of press releases issued by medical journals to describe research findings by their physicians and scientists and the subsequent media reports of those very same findings. The CliffsNotes version of their findings is that we have a problem in academia, and our hands are not entirely clean of the taint of misleading and exaggerated reporting. The version as reported by Schwartz et al in their article published in BMJ entitled Influence of medical journal press releases on the quality of associated newspaper coverage: retrospective cohort study. It’s an article I can’t believe I missed when it came out earlier this year. (more…)
I don’t know how I’ve missed this, given that it’s been in existence now for a month and a half, but I have. Regular readers (and even fairly recent readers, given that I write about this topic relatively frequently) know that I’m not a big fan of the National Center for Complementary and Alternative Medicine (NCCAM). (Come to think of it, neither is anyone else writing for this blog.) Just search this blog for “NCCAM” if you don’t believe me. I’ve explained the reasons many times, but the CliffsNotes version is that NCCAM is an enormous waste of taxpayer money, dedicated as it is to the study of modalities that are at best highly implausible and at worst break well-established laws of physics (i.e., “energy healing”). I do concede that, since the latest NCCAM director (Dr. Josephine Briggs) took over, there has been a noticeable attempt to bring more scientific rigor to NCCAM, and to some extent Dr. Briggs has succeeded. At the very least she is a legitimate scientist with an impressive pre-NCCAM track record, and I do fear who will succeed her when she moves on or retires given that there is enormous pressure from the CAM community to appoint one of their own as director.
Unfortunately, as rigorous a scientist as Dr. Briggs was in her former life, since coming to NCCAM she has gradually been assimilated into the culture of the place. Indeed, although it is good that NCCAM has backed away from studying woo like homeopathy and distance healing, the co-optation of science-based modalities such as exercise, diet, and natural products pharmacology has continued apace. Worse, the recently released five year strategic plan for NCCAM admitted that the science funded by NCCAM in the past was crap and, in essence, promised to do some real science for a change. That’s why on occasion I’ve jokingly said that we should take off and nuke NCCAM from orbit. It’s the only way to be sure. On the other hand, no doubt someone would think I seriously mean that we should nuke NCCAM. Of course, I’d never advocate that! NCCAM is located right smack dab in the middle of the NIH campus. The collateral damage would be unacceptable.
I wondered about the breakdown of the comments by both specialty and opinions about SBM. So I read the 226 comments and classified them by field and response. I classified each response as disapprove, approve or nuanced. It is not, obviously, a legitimate survey and there was more than a little subjective interpretation in deciding how to classify the responses. I have no doubt that others would get different results; it is not methodologically sound analysis. The discussion was in the Family Medicine & Primary Care section, so it is unlikely to be representative of any population, including that of Family Practitioners and Primary Care Physicians. I would bet, as in alternative medicine and most topics, Shruggies predominate and are the silent majority.
Even though I belong to what a commentator referred to as the not so silent “militant wing” of SBM, I was surprised at my results: (more…)
One of the major themes of this blog has been to combat what I, borrowing a term coined (as far as I can tell) by Dr. R. W. Donnell, like to refer to as “quackademic medicine.” Quackademic medicine is a lovely term designed to summarize everything that is wrong with the increasing embrace of so-called “complementary and alternative medicine” (CAM) or, as it’s increasingly called now, “integrative medicine” (IM) into academic medical centers. CAM/IM now a required part of the curriculum in many medical schools, and increasingly medical schools and academic medical centers seem to be setting up IM centers and divisions and departments. Fueled by government sources, such as the National Center for Complementary and Alternative Medicine (NCCAM) and private sources, such as the Bravewell Collaborative (which has been covered extensively recently not just by me but by Kimball Atwood, Steve Novella, and Mark Crislip), academic medical centers are increasingly “normalizing” what was once rightly considered quackery, hence the term “quackademic medicine.” The result over the last 20 years has been dramatic, so much so that even bastions of what were once completely hard-core in their insistence on basing medicine in science can embrace naturopathy, Rudolf Steiner’s anthroposophic medicine, reiki and other forms of “energy healing,” traditional Chinese medicine, and even homeopathy, all apparently in a quest to keep the customer satisfied.
Of course, in a way, academia is rather late to the party. CAM has been showing up in clinics, shops, and malls for quite a while now. For example, when I recently traveled to Scottsdale to attend the annual meeting of the American Society of Breast Surgeons, I happened to stop in a mall looking for a quick meal at a food court and saw this: