Respectful Insolence

It’s things like this over at Over My Med Body! that show our friend Graham really knows how to make a humble guy like Orac feel the love:

Big name bloggers like Orac and Dr. RW and KevinMD are all up in arms about how “medical schools are going the wrong way” and asking “Does anyone in academic medicine care about the integrity of medical education?” They like to talk about the fluffy “woo” of medical school, as if we’re all hippies out in our commune who have sacrilegiously sacrificed our Evidence and Data to a golden cow.

Give. Me. A. Break.

They’re whining as if this is the most scandalous thing to have happened to American Medicine. Are you kidding me?

See? Graham called me a “big name blogger.” Truly he knows the way to blogger’s heart.

Sadly, I must assure him: Even though I’ve reached a level of traffic that I would never have dreamed possible (having recently gotten more traffic in one day than I usually get in an entire week, thanks to a Reddit mention of this post), at heart I’m still that itty-bitty blogger from two years ago when I first started out. But if he thought that flattery would forestall a little taste of Respectful Insolenceā„¢ in return, he is sadly mistaken. However, it’ll just be a little taste because, although he’s thrown a straw man or two and a red herring up in criticizing my position with regards to alternative medicine, his heart appears to be in the right place and he does make a couple of good points. He just doesn’t seem to understand that the infiltration of woo into medical schools that I routinely complain about would almost certainly serve to worsen the very problem that he chastises me for not supposedly not emphasizing sufficently. I’ll explain.

But before I get into that, I would like to clear up the apparent misconception that I don’t criticize the sorts of things he apparently things that I should. For example, very early in the history of my blog, I made a big stink about the proliferation of imaging facilities that sold “screening breast MRI” and other expensive “screening tests” of dubious utility. I’ve also been critical of “bandwagon effect” and how confirmation bias can lead to the widespread adoption of a medical procedure before there is solid evidence of its efficacy. One might argue that my criticism of such misadventures is far outnumbered by my posts on alternative medicine and maybe have a point. However, the reason I post about “alternative” medicine and quackery is because I’ve taken a special interest in them, just as Graham appears to have taken an interest in the influence of money and big pharma in medicine. The two are not unrelated.

But let’s hear Graham’s specific complaint about us old geezers:

This is the same American Medicine (and academic medicine) that has played a part in the Vioxx scandal, who often have so many industry ties to their work that it’s hard to know if anyone is objective anymore. This is the same medical system where doctors at prestigious medical centers install medical devices and get a kickback, where doctors (academic and non) get paid big bucks to sign their patients up for clinical trials, and get flown to lavish vacations for industry-sponsored “education.” (I could dig up more examples if you really want.)

I’d ask these bloggers: Does anyone in medicine care about the integrity of medicine? If they don’t do any of these unethical things, great, but if you’re that upset about “integrity,” why not take a stand and try to change the system?

This is nothing more than a “why don’t you rail against what I think you should rail against?” argument. I could just as well counter by asking Graham whether he cares about evidence-based medicine and why he isn’t taking a stand to try to prevent the infiltration of quackery into medical school curricula. (And make no mistake about it, along with the alternative medicine that may have efficacy, there is quackery tagging along, quackery like homeopathy, which AMSA, for example, treats with an entirely uncritical, unscientific eye.) It’s a red herring, and a bit of a straw man as well (at least by implication), as I never claimed that the infiltration of woo into medical education is the “most scandalous thing to have happened to American Medicine.” I’ve merely argued time and time again that it’s a bad thing that will ultimately harm medical education and the ability of the next generation of physicians to practice evidence-based medicine . I will continue to do so. Also, the implication that we three “big name bloggers’ don’t care about corruption in medicine is also unfair at least to Kevin, M.D., given that he not infrequently posts about the very sorts of ethical misadventures and chicanery Graham so decries.

So, yes, I agree that it’s a very bad thing that doctors lose their ethical moorings, as in the example he describes above, and that pharmaceutical companies often have too much influence. I would, however, point out that there appears to be an increasingly strong reaction against this latter phenomenon, given the way pharmaceutical representatives and pharmaceutical company reps are increasingly becoming pariahs in medical offices. And I would emphasize that being concerned about one problem in medicine (the infiltration of woo into medical school curricula and the championing of woo by AMSA) neither precludes nor necessitates being critical of the other. The medical system now has a number of problems and challenges; more than one can be bad. Basically, Graham’s heart is in the right place, but his complaint seems to be simply that my concerns don’t jibe with his concerns sufficiently.

Graham also can’t resist throwing up a bit of a straw man:

Either way, many patients use CAM, whether I think it’s a good idea or not-and honestly, I’d much rather have some sort of idea about what CAM is and what I need to know about it than be ignorant of it completely. Some herbs affect medication dosages, for instance. While I’m not ready to go advocate for my patients to take Chinese herbs for their liver failure, I unfortunately don’t get to control what they do in their own free time. I’d prefer to meet the patient where he or she is at than write them off or be ignorant when they ask me a CAM question. (And yes, Western Medicine is still lacking in the “cures” department-if a placebo effect helps someone, should we honestly ruin it for them if we don’t have anything better to offer?)

Nowhere have I ever said it’s not a good idea for a physician to know something about CAM modalities, and I’ve especially never advocated “writing patients off as ignorant when they ask a CAM question,” which is the position that Graham seems to be attributing to those of us who have been pointing out the problems with introducing CAM into medical education before it has a sound evidentiary basis. Physicians should have a basic knowledge of what such modalities are and of potential drug interactions with, for example, herbal medicine for the very reason that they may need that information to educate patients. And if that were all that medical schools were introducing into their curriculae, I would probably have few, if any, complaints about it. But that’s not what many medical schools are doing. The infiltration of woo into medical school that is occurring now is goes far beyond simply educating physicians about these modalities so that they know a bit about them, can discuss them with their patients, and know potential drug interactions. The problem is that what is happening in American medical schools has morphed into open advocacy of these non-evidence-based and scientifically highly implausible modalities. AMSA, for instance, is strongly advocating non-evidence-based “alternative” medical modalities, promoting CAM fellowships, and even listing ways to be certified in quackery such as homeopathy. Medical schools, for their part, are also promoting non-evidence-based CAM modalities, with one, Georgetown, going so far as to incorporate woo into every stage of the education of its medical students.

The one thing that Graham is correct about is that the infiltration of woo into medical schools is probably driven largely by money. Insurance companies don’t pay for this stuff); it’s all cash on the barrelhead for physicians, hospitals, and practitioners. Even better, it’s cash without that nasty, painful paperwork to apply for reimbursement. Some physicians will answer this demand, whether there’s evidence that any of this stuff works or not, particularly since insurance companies, which formerly didn’t pay for any of this stuff (mainly because there was no good evidence that it worked), are being pressured by patients to cover CAM. Too, for whatever reason, over the last decade or so CAM has also become trendy, and organized medicine is prone to fads and bandwagons in terms of treatment, more so than it should be. Usually these fads eventually yield to the evidence, but alternative medicine thus far has been resistant.

In fact, let me propose how these two problems (“alternative medicine” woo and pharma or medical device woo) are linked and why I view the former as a profound threat. True evidence-based medicine applies the scientific method, skepticism, and critical thinking to the claims of big pharma and the device manufacturers just as much as to the claims of “alternative medicine.” Consequently, training the next generation of physicians in skepticism, critical thinking, how to evaluate the medical literature, and how to practice EBM would actually help inoculate them against the very problems that Graham is so concerned about. Part of the reason that pharmaceutical companies can hold such sway, that the use of devices of dubious value can become so prevalent, that treatment fads can sweep through medicine regardless of cost or lack of demonstrated efficacy is because the vast majority of doctors don’t have a firm grounding in practicing evidence-based medicine; they are thus vulnerable to the siren call of trendy CAM modalities just as much as trendy new devices. Heck, they’re already too vulnerable to the call of pseudoscience such as “intelligent design” creationism now! We don’t need to risk making them more so by blurring the line between science and non-science, evidence-based medicine and woo, through the enthusiastic promotion of CAM in medical school curricula.

And that’s why the infiltration of woo into medical schools concerns me so much. Medical school is the time where prospective new doctors acquire the basics of medicine. That means the scientific background behind diseases and how they are treated and the well-accepted standard of care for treating them. If, as part of those basics, they are taught, for example, that the contention that it is possible to dilute a substance to the point where not a single molecule remains and still have a therapeutic effect (as homeopathy teaches) is anything other than unscientific spiritual mumbo-jumbo and that it’s an acceptable alternative to use such woo to treat patients, their ability to recognize dubious claims by big pharma will likely become as impaired as their ability to recognize the dubious claims made for many forms that woo takes. Students will be likely to become doctors who are more, not less, likely to believe big pharma and fall for inflated claims for drugs and devices.

Indeed, I view the problem of big pharma’s influence on the practice of medicine and the infiltration of woo into medical schools and then into American medicine to be of a piece, part and parcel of the same problem: insufficient critical thinking and applications of science. They are driven primarily by two things: The dollar, as Graham notes, and insufficient skepticism, critical thinking , and application of true EBM, which is what I rail against. Teaching skepticism won’t do much about the former, but letting non-evidence-based therapies that are based on ancient concepts of vitalism find their way into medical school curricula has the very real potential to make the latter problem even worse, leading to a generation of physicians who have difficulty telling science from non-science and applying the most rigorous standards of EBM to their practice of medicine. Would teaching EBM and the application of skeptical thinking to the medical literature be a panacea? Of course not. But weakening, rather than strengthening, the foundations of the scientific method and EBM in medical school curricula by teaching non-EBM woo based on ancient concepts of vitalism is certainly not going to help physicians recognize dubious claims by big pharma or device manufacturers.

I hope Graham will someday see that that’s something worth fighting against.

Comments

  1. #1 anonimouse
    February 1, 2007

    You hit it on the head, Orac.

    Yes, pharmaceutical companies are attempting to over-influence medical practice. But it’s because doctors don’t apply common sense (much less advanced thinking and logic) that their influence becomes a serious problem. If they’re taking the word of Ginger The Cheerleading Pharmaceutical Rep over what the published science and clinical research says, then that speaks poorly of the individual and their training more than any endemic flaw with mainstream medicine itself.

    But woo is worse, because at least with Big Pharma has some kind of government oversight to keep them from putting useless and dangerous products on the market – and if they do, those products don’t stay on the market very long. The unregulated “supplement” industry can basically market whatever they heck they want, and for doctors who peddle them (and other bogus, quack therapies) it can be far more lucrative than the occasional free dinner or vacation from a drug company.

    The root cause of both problems is inappropriate medical education combined with a lack of critical thinking skills. Until you fix that, neither of these problems will go away anytime soon.

  2. #2 Abel Pharmboy
    February 1, 2007

    My observation at several med centers has been that faculty workloads are so tight that no one wants to take on yet another committee assignment of looking into the actual content of this CAM coursework. I’d tend to fault curriculum committees who don’t quality-control the content of what is actually taught. I share Orac’s view that docs need to know some stuff about CAM (like my post today about prepubertal gynecomastia resulting from lavender and tea tree oils), but more from the aspect of knowing what patients are doing out there that might complicate medical issues (drug-herb interactions, etc.).

    All too often, CAM coursework is presented in a very cursory fashion by faculty who act more as advocates than critical thinkers.

  3. #3 Kevin
    February 1, 2007

    An unclosed parenthesis is making your third paragraph difficult to follow.

  4. #4 quitter
    February 1, 2007

    Isn’t this just concern trolling? You know, the usual, “you should ignore x problem you’re railing against because y is more important.”

    You’re being kinder than I would be.

  5. #5 Orac
    February 1, 2007

    An unclosed parenthesis is making your third paragraph difficult to follow.

    It was a missing HTML tag. Oh well, you don’t expect me to be able to produce such copious verbiage without the occasional typo or missing HTML tag, do you?

    It’s fixed.

  6. #6 Hyperion
    February 1, 2007

    I see a huge degree of difference, though, between pharmaceutical influence and woo influence. Pharmaceutical companies are often guilty of taking a treatment for which there is ample scientific evidence of efficacy (vs. placebo), and misrepresenting it as meaning that the new expensive drug they are touting is therefore more effective than a cheaper generic competitor (even when said competitor may be a homolog or even enantiomer of the newer expensive drug). It is certainly essential for physicians to be able to figure out when there is a serious difference between two enantiomers (fexofenadine vs. terfenadine), and when it’s just a bunch of marketing bullcrap (loratidine vs. desloratidine).

    That being said, at least pharmaceutical companies are marketing treatments for which there is at least decent clinical evidence. If prescribed correctly by a trained physician, their treatment could be expected to actually treat a given condition. By contrast, the thing that sets medical woo apart from psychics and palm-readers in terms of vileness is the fact that they peddle false hope to people who may have serious health problems in need to treatment, and may prevent the timely application of effective treatment. There is a real-life obvious potential for serious harm in the non-abstract sense. While of course there is the greater question of medical school education and the broader need to strengthen evidence-based decision making that applies to both cases, the potential for harm is far more serious in the latter.

    Of course, that being said, if you want to play “why don’t you rail against this instead of that,” nobody seems to want to discuss the two third rails (third and fourth rails?) of medicine: The large population of uninsured persons and the future solvency of the Medicare system…ah crap, I wouldn’t want to touch either of those with a ten-foot pole, never mind, let’s get back to bashing woo :)

  7. #7 ukcommunitypharmacist
    February 1, 2007

    Hyperion: spot on re the enantiomers (or is it isomers, can never remember). Esomeprazole, desloratidine, levocetirizine are just money spinners that really serve very little purpose.

    What doctors should really do is speak to their local pharmacist who can tell them whether said drug is actually useful or not, and can also advise on drug-herb interactions (or at least know where to look).

  8. #8 Dangerous Bacon
    February 1, 2007

    I nominate the following topics in addition to Vioxx that Orac should be paying attention to instead of woo in the med school curriculum:

    Medical mistakes
    Hazards of estrogen replacement therapy
    Inflated doctor income
    Rampant acid-base imbalances
    Cancer-causing parasites
    The Codex Alimentarius Conspiracy

    Instead of contributing to a red herring or straw man argument, these topics (often brought up by alt med enthusiasts “responding” to specific criticism) are better described as tu quoques with a twist of lunacy.

  9. #9 Sastra
    February 1, 2007

    Graham wrote:

    (And yes, Western Medicine is still lacking in the “cures” department-if a placebo effect helps someone, should we honestly ruin it for them if we don’t have anything better to offer?)

    What does he mean by “ruin it for them?” Forbid patients to take so-called alternative medicine or throw them out of the office? Tell them the truth — that it’s not scientifically supported, but if it’s not hurting them they might as well take it? Or does he mean doctors should not “ruin it” for patients who have incurable problems, they should give them placebos and tell them they work? I thought that was called “lying.” Maybe it’s not lying if you figure out a way to believe it works, too. Which means something better to offer might be a long way away.

    Imo, the term “Western medicine” sounds so elitist and tribal.

  10. #10 Blake Stacey
    February 1, 2007

    The placebo effect is produced by the mind. Why, then, should it be any more effective than, say, psychoanalytic talk therapy? Can a sugar pill do any better than a smiling grandchild and the will to see next Christmas Day? I would like to know if any studies have been done showing that a positive but dishonest state of mind brings any greater benefit than a positive, truthful one.

  11. #11 DrDork
    February 2, 2007

    Hear, hear, Orac.

    Hit. Nail. On. Head.

    Awfully gentle on this chap !

  12. #12 Orac
    February 2, 2007

    That’s why I call it “Respectful” Insolence.

    Well, most of the time, anyway. For certain characters who deserve it, I drop the “respectful” part.;-)

  13. #13 Lucas McCarty
    February 2, 2007

    Here’s something you definately should stop talking about woo for and concentrate on instead: Urban myths of cracking fingers.

    I am pretty sure it’s just an urban myth that cracking your fingers causes Arthiritus(if I even spelt it right), invented by the squeamish out to stop our knuckle-crunching fun.

    But the less common retort to this could also be an urban myth: the ‘cracking’ is actually a ‘popping’ caused by air/gas being released from the joints as they flex, although there is no obvious explaination for how this air/gas got there in the first place.

    It needs addressing far more than woo because soon the quacks will start selling ‘treatments’ for it!

  14. #14 Amy Alkon
    February 4, 2007

    Actually, you’re like the magazine with a small audience — all of whom are millionaires. A few times, when I’ve met or run into somebody whose mind I respect, and I’ve recommended your site, that person’s already a fan. (A respected retired surgeon I met at a party, a science reporter who actually gets his facts right, etc.) Think quality, not quantity. Also, while your site is comprehensible to non-medical professionals (I’m a syndicated advice/humor columnist and I never have a problem), I recently got dumped from a daily newspaper for “not talking down to readers enough.” Seriously. The editor told me more people than you’d expect read at an eighth-grade level. (I know this, they write to me in broken, misspelled, grammatically bereft prose.)

  15. #15 Thursday
    February 23, 2007

    Sastra –

    “Western Medicine” is like “Western Science” – it only exists in the minds of those who want an enemy to rail against.

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