Wow. There was quite a response to yesterday’s piece about why doctors are seduced by the pseudoscience of “intelligent design” creationism, more so than I expected from what I thought might be a dry topic.
A couple of the comments provoked by the post are worth discussing briefly in a separate post, rather than my diving into the comments more, where my response would get buried. For example, Flex commented that many physicians are acting as technicians more than anything else. While agreeing with him that most doctors don’t need to be scientists, I would quibble with him about how much his a characterization of us as “technicians” applies. In laboratory parlance, a technician is usually someone with just a bachelor’s degree who makes buffers and reagents, maintains the lab, and does experiments under the close supervision of the lab manager. A technician is a skilled, but not professional or autonomous, position. I think his choice of words was poor, because there’s a lot more to medicine than “selecting the treatment option which makes to most sense to us” for patients; there’s a large human component, including counseling, teaching, and explaining to patients. There is dealing with less than optimal conditions and patients who are not compliant with their medications. There is dealing with the social conditions under which our patients live. But the basic point still stands, namely that most physicians are not scientists, nor should they be. There is keeping up with the medical literature. If an analogy must be made, I’m more comfortable with the comparison to engineers that others have made.
While it may be a shame that some technicians refuse to understand the underlying knowledge which makes their work effective, this does not mean that the technician’s treatments are ineffective.
I reserve the term ‘quack’ for those who not only disregard the underlying principles of a profession, but also substitute known ineffective treatments in place of known effective ones. Alice can still be a very effective physician without knowing the underlying principles which generated the medical knowledge she is using. This does not make her a ‘quack’.
Of course, not understanding the underlying principles of a profession is a gateway to ‘quack’ beliefs. Like electronics technicians falling for ‘vacuum-state’ free energy machines (and I’ve known a couple), not clearly understanding the underlying principles behind a profession prevents a person from spotting claims which violate those underlying principles. That is an open invitation to ‘quack’ ideas.
Exactly. The reason it is so critical for us physicians to have a solid understanding of the scientific method and of the science behind our treatments plus the critical thinking skills to apply this knowledge, be it as a “technician” or a scientist is to allow us to apply those skills to the evaluation of new treatments (or even old treatments that we haven’t heard of before). I consider uncritical acceptance of a pseudoscience, especially a pseudoscience as easily refuted as young earth creationism, to be a marker of a tendency that is very worrisome in a physician: credulity when it comes to the claims of pseudoscientists and quacks. Indeed, belief in creationism (and we’re not even talking the superficially more plausible-sounding stepchild of creationism, “intelligent design”) goes hand-in-hand with a lack of critical thinking skills that leave one open to other pseudoscientific beliefs of many varieties. A few months ago, I wrote before about how credulity about creationism can be associated uncritical acceptance of bad medicine and used the granddaddy of the ID movement himself, Phillip Johnson, as an example because he is both an ID creationist and an HIV “skeptic”:
How could a deputy editor of the NEJM fail to mention such an important point about how credulous thinking about evolution goes hand in hand with credulous thinking about medical science? Phillip Johnson is a poster boy for exactly the sort of thinking that we don’t want to see in our medical students and residents. He is Exhibit A of how poor critical thinking skills and lack of understanding of the scientific method can go hand-in-hand with the acceptance of multiple types of pseudoscience. Dr. Schwartz must be either unaware of Phillip Johnson’s opinions and activism with regards to HIV, or he must have chosen to ignore the topic. (I’m not sure which explanation for this lapse would be worse.) Given the huge problem of non-evidence-based medicine and even outright quackery, Dr. Schwartz could have asked the question: Do you want future generations of doctors to be credulous with regards to the claims of pseudoscientists and quacks? Letting pseudoscience into the science classroom under the guise of a legitimate “alternative to evolution” is certainly one way to undermine a student’s ability to learn the scientific method. Not a good thing for future doctors!
True, Phillip Johnson is not a physician–fortunately. However, my concern for medical students or physicians who are creationists is that their belief in a pseudoscience is an indicator that they might be susceptible to the blandishments of various quacks or to the siren call of quackery. Most of them may may never fall under that spell by somehow compartmentalizing their religious beliefs away from their day-to-day practice and study. I certainly hope that’s the case with Alice. However, the list of doctors who have fallen into quackery is, sadly, a long one, and for a significant number of them their religion goes hand-in-hand with their quackery. For example, Dr. Lorraine Day, while peddling anecdotes about breast cancer and her videotapes uses a lot of religious language on her website. She even castigates people who would doubt her story with a threat of God’s wrath. By all accounts, Dr. Day used to be a competent orthopedic surgeon and, indeed, was on the faculty at UCSF in the 1980′s. Now she peddles religion-inspired “natural treatments” like Barley Green, videos, and books on her website. Unfortunately, Dr. Day is not alone, Dr. Larry Dossey is another example, having written books about using prayer to heal and dubious-sounding techniques of “mind-body” medicine, not to mention cowriting a book about the power of Native American healers to produce “miracles“. There are many other examples.
Also, there is the issue of what a physician does when his religious beliefs conflict with his duty to his patients. For example, does he deny birth control pills to regulate a woman’s irregular and painful menstrual cycle because he disapproves of birth control? Or what about a doctor who is a Jehovah’s Witness and encounters a patient who is bleeding to death? Or what if stem cell research actually fulfils some of its promise and yields highly effective treatments for diseases like Parkinson’s disease? Does a religious physician who believes abortion is murder withhold such treatments from his patients? I’ve come across antivaccination advocates who base their objection to vaccines on the fact that for some vaccines the viruses used to develop the vaccine were propagated in “fetal cells” (in actuality cell lines derived from fetal tissue and continuously cultured since then). Will a physician whose religious beliefs tell him that abortion is murder be able to recommend disease-preventing vaccinations to children because their development and manufacture involves culturing virus in a cell line derived from a fetus aborted over 40 years ago?
But I digress.
After some thinking, it’s clear to me that the problem is deeper than just evolution. Physicians need to be versed in the scientific method, critical thinking, and the ability to read the scientific literature. We also need to develop a bit of humility to refrain from pontificating about topics that are outside of our realm of expertise and realize when we don’t know what we’re talking about.
Of course, some other comments asked where we would find in the medical school curriculum to teach evolution. That’s a good question. I have to wonder that myself. On the other hand, somehow some medical schools seem able to find time in the curriculum to offer an art appreciation course to its students. Even though I have lamented that I never took more time in college to study the humanities and broaden my horizons, I strongly question whether medical school is the place to be trying to make up for that lack in medical students, unless they plan on being medical illustrators. Medical school is a professional school. It exists only to train doctors. Period. Anything that does not contribute to the training of excellent doctors is extraneous. Of course, at the very worst, studying art is a neutral or benign diversion from learning medicine. I’d take that over what some medical schools are making room for in their curriculum, namely topics that are downright detrimental to critical thinking skills and medical education, specifically woo-filled and non-evidence-based courses on “alternative” medical therapies. Some even include the teaching of such quackery as Reiki therapy, homeopathy, and other dubious alt-med treatments! They’re even starting to offer CME in it. It wouldn’t bother me so much if these were taught in a rigorous, evidence-based fashion examining the evidence (or mainly the lack thereof) for these therapie. Such a strategy would help new doctors to understand the therapies that many of their patients are using with or without their knowledge and be able to determine which ones have evidence to support them (very few) and, more importantly, which ones don’t (the vast majority). Unfortunately, such does not seem to be the case at too many medical schools that are jumping on the bandwagon, which instead seem to teach these unproven therapies in a disturbingly data-free and uncritical manner. (Note: This topic may well be future blog fodder; as I’ve come across a curriculum document for teaching alt-med in medical school.)
As far as I’m concerned, courses in evolutionary biology, in contrast, would contribute to the training of physicians far more than either courses in art or credulous courses on non-evidence-based alt-med therapies and, if I had my way, would supplant them. Training in evolution would help to prepare the next generation of physicians not only to apply the findings of evolutionary biology to improving human health and developing treatments for disease. It would also have the salutory effect of providing additional training in science and critical thinking that could innoculate budding physicians from at least some of the credulity that even the most educated person finds hard to avoid–rather than contributing to such tendencies, as medical schools are sadly beginning to do with their unskeptical treatment of alternative medicine.