If you're a physician, there comes a certain point in your career when you start caring a lot more than you did about the next generations of physicians in the training pipeline. While you're in the middle of training, you are the next generation; besides, you're too worried about just getting through medical school, residency, and Board certification to be all that concerned about those behind you in the pipeline, anyway. Then, when you're early faculty, you're concerned about establishing yourself, getting your career on track, and, if you're in academics, getting promoted. True, physicians who aren't interested in education wouldn't be in academics in the first place, but most of us tend to be far more concerned about resident education, because these are the people who will be replacing us one day in our own specialties. At some point, however, one starts wondering about the next generation of doctors that will not just be replacing one's own specialty, but will be becoming the next generation of primary care doctors, internists, and other specialties aside from one's own. Part of this interest in self-interest. After all, we're all getting older, and aging physicians will need doctors too. More importantly, though, most physicians like to think that their profession is improving and that the next generation of physicians will surpass the present generation, thus insuring continued improvements in the science and art of medicine. We like to see our generation leaving a legacy of improved patient care and part of that legacy is the training of medical students.
Unfortunately, I have seen what may be the future of American medicine, and now I'm very concerned. Dr. R. W. has shown it to me. The American Medical Student Association (AMSA), an organization that should be committed to advocacy of the finest training and the best scientific medicine, is deep into promoting woo among medical students.
Dr. R. W. was concerned about this pushing of pseudoscience as an instance of hypocrisy, given that AMSA is promoting a national "Pharm Free Day" on November 16, in which AMSA urges hospitals and medical schools to restrict access by pharmaceutical representatives to students, residents, and physicians, with a sanctimonious statement in which they seem to claim they are doing this in the name of evidence-based medicine:
AMSA members believe in providing the highest quality care through evidence-based medicine. Here's how.
I'm less concerned with the hypocrisy (although Dr. R. W. is perfectly correct to point it out) and more concerned with the woo that AMSA is actively promoting among medical students. Indeed, AMSA publishes a Complementary Therapies Primer, which is full of credulity towards many forms of woo. It wouldn't be so bad if it were just herbal medicine being promoted. After all, some herbs do indeed contain active compounds that definitely do have pharmacological activity and can be used to treat disease. (Just ask Abel Pharmboy.) It is almost certain that we will continue to find new natural products and plants that harbor substances that can be used as drugs to treat disease. The stuff on yoga, meditation, and other relatively innocuous woo doesn't bother me too much either, as long as it doesn't claim to treat disease. But AMSA goes way, way beyond that. Some examples follow.
AMSA on traditional Chinese medicine (p. 5):
Traditional Chinese Medicine (TCM) is an ancient method of health care that combines the use of medicinal herbs, acupuncture, food therapy, massage and therapeutic exercise. It has proven helpful for many conditions, including chronic degenerative disease, cancer, infectious disease, allergies, childhood ailments, heart disease and AIDS.
Really? How? Based on what evidence? AMSA doesn't say. It simply goes on:
TCM also introduces a major component of the body, qi, that Western medicine does not even acknowledge. Qi is what is called the life force, and it is all inclusive of the many types of energy within the body as well as being essential for life itself. This vital life energy flows through the body following pathways called meridians. These meridians flow along the surface of the body and through the internal organs, with each meridian being given the name of the organ through which it flows, such as "liver" or "large intestine." Organs can be accessed for treatment through their specific meridians, and illness can occur when there is a blockage of qi in these channels. Therefore it is essential in TCM to keep the qi flowing in order to maintain health. The healthy individual has an abundance of qi flowing smoothly through the meridians and organs. With this flow, the organs are able to harmoniously support each other's functions.
Again, there's no evidence presented for qi or any of the other mystical mumbo-jumbo discussed without skepticism. And, most outrageous of all:
TCM is well suited to anyone looking for safe healing, answers he or she can understand in everyday human terms, and involvement in and responsibility for his or her own healing.
On what studies or evidence does AMSA base these assertions, particularly the last one, in which AMSA explicitly states that TCM is "well-suited" to a certain group of patients? None whatsoever. The references are all books on TCM and acupuncture. There's not a single peer-reviewed scientific study or clinical trial listed in the references for TCM. There's not discussion of the lack of scientific evidence even for the existence of qi (and scientists have looked and continue to look; I've seen grant applications in which the applicants propose trying to measure qi without success or hope of success). Moreover, there is little or no skepticism or critical thinking. It's all warm and fuzzy acceptance. Don't believe me? You can read the whole thing yourself, or you could check out a couple of more examples.
AMSA on reflexology (p. 9):
Reflex areas in the hands and feet are believed to correspond to every part of the body, which may in turn be affected by stimulating the associated reflex areas. Reflexology is useful in relief of stress and tension, stimulation of relaxation, improving blood supply and unblocking of nerve impulses, thereby normalizing and balancing the entire body. Precise pressure is applied to release blockages inhibiting energy flow and causing pain and disease. Nerve endings in the feet are felt to connect with all areas of the body. Although medically unproven, there is a wealth of anecdotal evidence as to the effectiveness of this approach.
In other words, there is no good evidence other than the testimonials of the adherents of reflexology that it does any good treating disease. Certainly none of the references cited are in the peer-reviewed literature. They don't even appear to be attempts at a critical evaluation of this technique. In fact, they don't appear to be anything more than tomes written by advocates, and not even a single example of this so-called "anecdotal" evidence is cited or listed.
Before I go on, I can't resist citing one more example from p. 18:
Fasting has been used as a means of physical, mental, and religious purification for centuries. Modern holistic medical practitioners are now recognizing its value in health maintenance and promotion.
Fasting eliminates the work required to digest and metabolize food, and allows the body to use stored fats as fuel. While fasting, fewer toxins are absorbed by the body, yet toxin elimination continues at the normal rate. Food allergens are eliminated, allowing the GI system to rest. After four days of fasting, serum fats are lowered, and the thinner blood circulates more effectively, leading to greater oxygenation and better immune function. Fat burning allows the release and elimination of fat-stored toxins such as pesticides.
Fasting has been used to benefit hypertension, headaches, allergies, arthritis, fibrocystic breast disease, schizophrenia, and, of course, obesity. Fasts may vary from two days to several months, depending on the condition to be treated. Fasting longer than a few days can be dangerous, however, and should only be done under the care of a health professional.
Fasters should consume an adequate amount of liquid. Experts are divided as to whether pure water or vegetable juice is the ideal replacement. Juice fasts are better suited to patients with poor dietary habits, who will undergo a vigorous detoxification phase of the fast. Patients may take a "detoxifying cocktail" of garlic, lemon, grapefruits and olie oil to flush out the liver at bedtime. Many practitioners encourage use of enemas while fasting.
I refer readers to the following old posts by yours truly for discussions of this sort of "detoxification" woo, which is an altie staple that is not only not supported by science but creates the appearance of "success" by producing the very "stones" that the "liver flush" claims to eliminate:
Would you like a liver flush with that colon cleanse?
Mere regularity is not enough
The Orange Man
Even worse is, though, the credulous treatment of homeopathy on p. 19 (yes, I couldn't resist just one more example):
The Law of the Infinitesimal Dose was formulated by Dr. Hahnmann when he experimented with dilute solutions, seeking to avoid toxicities, and found them to be more effective than full strength preparations. Homeopathic remedies are repeatedly mixed with water or alcohol and shaken (succussion), often diluting the substances to such a degree that no amount of the original medication can be found in the remedy. Some believe that the remedies retain their
effect because of electromagnetic frequency imprinting, changing the structure of the diluent subtly.Initially, as a patient is treated by a homeopathic physician, he or she may actually worsen. This is know as a "healing crisis." As the presenting, most recent, symptoms are treated, older, underlying disorders come to the surface. Dr. Constantine Hering, the father of American homeopathy, believed that healing progresses from recent diseases to chronic maladies, from emotional imbalances to physical disorders, from superior to inferior, and from the deep structures to the superficial. This is known as Hering's Laws
of Cure. By following Hering's Laws when treating a patient, a practitioner can successively unravel many layers of pathology, eventually recreating internal order and achieving a more permanent cure.Homeopathy is used to treat diabetes, arthritis, asthma, epilepsy, rashes, allergies, mental and emotional imbalances, and the common cold, as well as many other conditions. Homeopathic remedies are very inexpensive and nontoxic, and many reports document their success in a variety of situations. Homeopathy, while popular in the early twentieth century, has lost favor with the medical establishment in the US.
There's a reason that homeopathy has "lost favor" with the medical establishment. (Actually, it never really had much favor with the medical establishment in the first place.) That's because it's utter bunk. Indeed, even physicians of the 19th century, physicians like Oliver Wendell Holmes, could quite convincingly show why homeopathy is utter bullshit. (Sorry, there's just no other word for it that describes homeopathy as well.) It makes me despair for our medical education system that AMSA, an organization run by medical students is publishing such a credulous treatment of pseudoscience like homeopathy. Didn't they learn anything in undergraduate and medical school? Apparently not. Our medical schools seem to have failed to teach them basic chemistry, physiology, and pharmacology, leading to statements like this regarding the evidence supposedly supporting woo:
Proponents of CAM therapies argue that unconventional treatments often cannot be tested effectively by the traditional, double-blind, controlled format that is the hallmark of conventional scientific studies. According to Manuel J. Avancena, L.Ac., an acupuncturist in Reston, Virginia, acupuncture points are different for every patient. If five patients present with the same primary complaint, the treatment will be different for each patient depending on coexisting symptoms or problems. This holistic component of the treatment would not be effectively measured by a study that demands that each patient have the same points treated in order to control variability.
People more skeptical of CAM demand nothing less than the double-blind, controlled study with objective results before they consider CAM. To some, the very argument that CAM cannot be evaluated using the controlled, double-blind study indicates that CAM is equivalent to quackery. In addition, scientists and physicians often remain doubtful if a therapy works but little evidence is available regarding the mechanism of its effects.
Guilty as charged, with one exception. (I'm funny that way. I'm alway skeptical of treatments that don't appear to have any physiological or scientific basis for "working." In fact, I'm even more skeptical when the evidence that such treatments actually "work" is so flimsy.) The above is nothing more than a typical altie strawman that skeptics require "nothing less than the double-blind, controlled study with objective results." True, that is the gold standard towards which we strive when evaluating a therapy, but evidence-based medicine does not demand only double-blind, randomized, placebo-controlled clinical trials before it will consider a treatment, as I have explained before. When weaker evidence is all that is available, evidence-based medicine must synthesize it as best it can and come up with recommendations. AMSA does get one thing right, though. If an advocate of a treatment claims that it can't be evaluated by the scientific method, I become suspicious of quackery--and rightly so, I argue. Even if, as claimed, "every patient requires a different treatment" under this system, it should still be possible to determine using the scientific method exactly why and to identify the criteria upon which the "individualized" treatments should be based. Conventional medicine "individualizes" treatments too, but it doesn't have the temerity to claim that such individualization can't be studied scientifically. In conventional medicine, no treatment is assumed to be impossible to study scientifically, and CAM should be treated no differently than "conventional medicine." It is true that certain treatments may be very difficult to apply the scientific method to, but that does not mean that we should throw up our hands, give up, and just take the alties' word for it that their treatments work. We should treat their claims exactly the same as any claim by academic physicians or big pharma.
But AMSA's promotion of woo goes beyond even this. AMSA is going so far as to hold what it refers to as a "Leadership Training Program for CAM." Here's the goal:
The LTP is an experience of a lifetime. 20 medical students from across the country will gather on the campus of the Omega Institute for a weeklong, intensive retreat dedicated to complementary and alternative medicine and leadership skills training. Our expectation is that these 20 students will go on to become the future generation of leaders in CAM education in their medical schools and beyond.
During the LTP, students will learn from expert facilitators about a number of CAM topics- everything from acupuncture to research to mind-body medicine to the latest in regulation and licensing standards for CAM. Stress reduction, wellness, and nutrition will also be emphasized throughout the week as students will enjoy healthy meals and will have opportunities to take classes in meditation, Yoga, and movement. To enhance leadership skills, LTP facilitators will host sessions on public speaking, interpersonal skills, teamwork, and other activities designed to make YOU a more effective advocate for CAM.
In addition, each participant will plan a project to increase CAM awareness at his or her school. The LTP facilitators will host sessions throughout the week to help you make your project a success!
Great. Just what we need, a project promoting the credulous acceptance of the claims of alternative medicine by future generations of doctors. But that's not all. In April, AMSA is sponsoring a woo-filled four week elective in in communal living, alternative medicine, and activism. Yes, we're talking about a group bonding experience largely based on the credulous acceptance of the claims of alternative medicine (plus a some left-wing activism thrown in for good measure) in future generations of doctors. (The left wing activism doesn't bother me that much, but I do find the emphasis on woo highly disturbing.)
There are a couple of truly ironic aspects of this credulous support of alternative medicine by AMSA. Perhaps the most amusing is the frequent claim by alties that the AMA "suppresses" the "truth" about alternative medicine. Yet, here we have AMSA, the premiere organization for medical students, swallowing the altie line, hook, line, and sinker. True, AMSA is not a branch of the AMA. However, it is the largest organization representing medical students, and consequently the leaders of AMSA are likely to be the leaders in medicine in general in the next 10-20 years. After all, any medical student who would be willing to go through what it takes to become a leader in a national society like AMSA will also be likely to become a leader in various local, state, and national medical societies and organizations after he or she becomes a physician.
The most ironic aspect of all, however, is that, while a major medical student organization in the U.S. is accepting traditional Chinese medicine and medical schools themselves rush to embrace it, the Chinese themselves, particularly Chinese youth, appear to be early in the process of rejecting TCM in favor of scientific medicine:
Traditional Chinese Medicine (TCM) is losing out to western medicine in the popularity stakes in China, according to an online survey.
Only 28 percent of the 14,677 respondents to the survey by China Youth Daily and Tencent.com said they would turn to TCM first even though 87 percent said they still had faith in the centuries-old practice.
Half of the respondents who voiced their support for TCM believe it is an effective cure for many diseases but 27 percent only trust it because it is "the quintessence of China". As for the future of TCM, more than 60 percent said they were not optimistic.
A nationwide debate erupted over TCM after an online proposal was submitted by Zhang Gongyao, a professor at Central South University, urging China's health authorities to remove TCM practices from its national health service. It attracted both support and outrage from thousands of netizens.
Supporters of the proposal labeled traditional Chinese medicine "unscientific and untrustworthy" and opponents lambasted supporters for ignoring history.
Indeed, one prominent Chinese physician has dared to speak out:
Mr. Zhang, a professor at Central South University in Hunan province who has been studying medical history for more than 30 years, is urging the government to stop promoting traditional medicine. He has launched an online petition to seek its removal from the constitution and the official medical system. And he wants China's traditional-medicine practitioners to get mainstream medical training.
"From the viewpoint of science, Chinese traditional medicine has neither an empirical nor a rational foundation," he wrote in an article that ignited a furor when it found its way onto China's Internet. "It is a threat to biodiversity. And it often uses poisons and waste as remedies. So we have enough reasons to bid farewell to it."
Although he has been largely vilified, he has also garnered a surprising amount of support:
The professor won a surprising amount of support on some Chinese websites. One person commented that traditional medicine needs to prove itself scientifically, or else it should be dismissed as witchcraft. Another person, a medical student, said she wished her university would stop teaching traditional medicine, which she regarded as mythology.
Chinese newspapers pointed out that China has about 270,000 traditional-medicine practitioners today, far fewer than 800,000 in the early 20th century. Meanwhile, the number of physicians trained in Western medicine has soared from 87,000 in the early 20th century to about 1.75 million today.
"If the government wants people to trust traditional medicine, it must make a greater effort to prove the reliability and scientific basis of traditional medicine," the respected newspaper Southern Daily commented. "Otherwise, traditional medicine will keep declining every day."
So, in China, the number of practitioners of evidence-based medicine is increasing, while the number of practitioners of TCM is decreasing. The exact opposite seems to be occurring in the U.S. Wouldn't it be sad if, just as China is starting to subject even its most deeply respected medical traditions to the scientific method and becoming willing to discard therapies that have no scientific basis, we in the U.S. start embracing the very same unscientific therapies that the Chinese are starting to reject in favor of evidence-based medicine? Yes, I will concede that parts of the literature on alternative medicine that AMSA publishes stresses that alternative medicine should be used in addition to conventional evidence-based medicine, but it doesn't reassure me much. I'm still having nightmares in which I picture myself old and with cancer, faced with a chipper young doctor, fresh out of residency, assuring me that I'll be just fine if I take the recommended homeopathic medicine and go through a "detoxification" regimen.
I fear for the future of my profession. My only hope is that AMSA is not representative of the vast majority of medical students. (I suspect that this is the case.) Even so, by claiming to be advocates of evidence-based medicine on the one hand while promoting unproven and unscientific therapies such as homeopathy and reflexology on the other hand, AMSA can't help but have a pernicious effect on the education of the current generation of medical students.
Scary. Will we have to conduct long detailed interviews when choosing our physicians in the future, to try to weed out the gullible ones?
Orac:
This article should not be here, it should have been sent to the AMSA, or any publication they publish. This is authentically scary, and I hope you, and others, will be doing everything in your power to fight this, including challenging such students to debates that can be disseminated over the web. I also hope this is reprinted in any blog carnival directed at or read by med students.
Orac wrote,
Case in point: G. Smith and J. Pell, "Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials", BMJ 327: 1459-1461 (20 December 2003). Perhaps my favourite paragraph:
(Found via Neil Gaiman's blog this morning.)
Wallace Sampson wrote a good article on this in "Academic Medicine (2001) 76: 248-250."
They left out St. Jude-I have as much faith in prayer to the patron saint of hopeless cases as I do in reflexology or homopathy.
Orac also wrote:
Doesn't conventional medicine deal with the fact that "every patient requires a different treatment" every day? Cancers grow in different places, are caught at different stages and respond to radiation or chemotherapy to varying extents determined by biochemical details of which we are all too ignorant. And yet the patients still live. Some even get better.
Oops, somehow the block quotation got fried in my last comment. It was supposed to be the following:
Let's see if this one works. . . Every blog comment needs its own treatment, don't ya know.
Thankfully, the med school I work for doesn't associate itself with such nonsense, and as far as I know none of our students are taking any woo-based fourth-year electives. At least in this class. Hopefully it stays that way.
I've said something similar to this with regard to your post on Suzanne Somers, but I'll say it again. AMSA, in one of the statements you quoted, talked about acupuncture points being different for each individual, and that this set of differences makes it impossible to test acupuncure in a double-blind study. For such a study, researchers have to use the same acupuncture points for everyone in order to test their effectiveness.
The bit about acupuncture points being different for each individual makes it ideal for people who want individual attention. If my points are different from yours, I'm getting individual attention personalized to me - something many of the altie crowd feel is lacking in those who practice conventional medicine, with its reliance on protocols to which the patient is forced to adhere without regard to individual needs.
Patients need to approach both alternative and conventional medicine with a skeptical eye, informed by independent research.
Yike. I wasn't aware of this group and its writings; I'd say thanks for the post if it weren't for the fact that it's deepened my already profound pessimism. Fortunately I've been concluding lately that if I get sick, I'll just sit outside in the winter with several well-made gins and tonic... When you add this to the concerns about the effects of the 80 hour work week on surgical training, well, good luck everyone...
TCM is well suited to anyone looking for safe healing, answers he or she can understand in everyday human terms, and involvement in and responsibility for his or her own healing.
This is what really scares me, that any patient who ever expresses a concern about safety, asks for a less jargon-filled explanation, or indicates a desire to be an active participant in the treatment decisions, is going to get labeled as "woo-appropriate" and referred to the house altie. I supose this will mean that you only get evidence-based treatment if you act oblivious to risk, comfortable with ignorance, and passive about your own care.
I hope acupuncture can cure the effects of banging one's head on the desk, since I guess I'm going to need it to someday if I live that long.
This IS scary! Now I feel like I need to wear a medical alert bracelet saying, "CAM ALLERGY-- USE EVIDENCE-BASED MEDICINE ONLY!"
The problem with woo is that: (a) it may not work and (b) it may be a waste of money.
The problem of conventional medicine, however, is likely worse, insofar as it kills 220,000 Americans each year (the third leading cause of death after heart attack and cancer).
I cite JAMA, Dr. Barbara Starfield from Johns-Hopkins.
Dr. Starfield tabulates the iatrogenic deaths each year in the USA.
* 12,000 deaths/year from unnecessary surgery
* 7,000 deaths/year from medication errors
* 20,000 deaths/year from other errors in hospitals
* 80,000 deaths/year from infections acquired from hospital staff or patients
* 106,000 deaths/year from adverse effects
That's 220,000 deaths per year, that ain't getting sufficient attention.
So, given this substantial amount of iatrogenic death each year, it does not surprise me in the least that woo is catching some interest in younger generations, even younger generations of physicians.
HankB
When I was a premed, I was the 'pre-medical liaison' for the Humanistic Medicine Committee. At the time, I wasnt aware 'Humanistic Medicine' was codeword for 'Woo Crew.' After a blow-up on the list-serve with an MD (keep in mind, I was a sophomore in college at the time) about her involvement in an intercessory prayer study (I was furious money was being wasted on that garbage instead of real breast cancer research) I quit being involved in AMSA on a national level, was entirely turned off of medicine, and subsequently decided to get a PhD instead.
If I were in medical school now, I would be fighting against this sort of thing. AMSA is a fantastic organization, and its a shame it is being tarnished with this sort of idiocy. Although, if its any consolation, the 'Hu-Med' people were somewhat isolated from the rest of AMSA. Not sure how they are accepted today.
I failed to mention in my last post that I've had some bad experiences with protocol-based medicine. When I got my transplant in 1979, the surgeon used a protocol-based approach - drugs were given in rigid doses according to the patient's weight, irrespective of whether the patient was sensitive to the side effects of drugs or resistant to the drugs. Stitches were taken out 14 days after transplant for everyone, even the slow healers who were unable to heal in time to have their stitches taken out. Individual differences were generally not respected, because if they were, then the attendings couldn't leave the day-to-day care of patients to the interns and residents (who didn't have the clinical experience to be able to tailor care to each patient's unique needs).
This is precisely the sort of care which drives many people into the offices of alternative-medicine practitioners.
Nice subject change you're hiding in there, especially since quackery is always malpractice and always unnecessary.
Hey there, I wanted to thank you for this, because the part on fasting helped me understand a weird phenomenon that happened this past Ramadan - several people who are not Muslim asked me about the details of how we fast and when I explained that it is really a question of just eating at different times, not actually going without food in a really extreme manner, and that we eat before dawn then don't eat, drink, smoke, etc. from dawn until sunset I got all this horrified "don't drink fluids at all? But that's bad for you! Aren't you fasting because it is a healthy thing to do?"
Finally I was like, you guys, the Ramadan fast is a religious ritual, it is not a new age health fad. It has rules that may or may not make sense from a health standpoint because health is not its primary aim, and why are you all talking about Muslim fasting as if it were?
They kept going on about how fasting flushes toxins and stuff like this and I was all like "huh?" If you don't want to ingest toxins then eat food that does not contain them, but why is fasting supposed to be good for you by itself? And then I heard this weird "I know these people who do a juice fast every month for 2 days and they are astoundingly healthy" and stuff like this. I was like, look, the Ramadan thing is definitely not like that. We are not into it for our health, it's a religious thing like praying. Leave me alone if you don't like the rules, because if you are not Muslim I can't imagine why you should care.
Now I sort of get what they were on about. They need some help. Guess they won't get it from the next generation of med students!
I know one of those people who thinks fasting is medicine. We actually had an argument where she claimed that the fuzzy feelings and difficulty functioning that comes at the beginning of a fast was the toxins leaving the body, and I claimed that it was the body entering starvation and was the result of low blood sugar. It's getting harder to talk to her these days.
Orac,
I guess I thought you already knew about this. Well, now you do, and I'm glad to see you're all over it in the usual inimitable Orac fasion. I've been beating this drum for a while but don't have near the audience you do.
AMSA, it looks to me, is the largest, most powerful and best organized group of med students. They're better established some places than others. You might want to snoop around and see what they're up to at your joint.
The students generally don't know what they're getting into when they join (much of the woo is buried deep, deep inside their huge web site) and they're induced to join with a free Netter's! I know this from lurking on student doctor forums and AMSA Google discussion groups.
Many influential academic faculty from all over the world collaborate, and offer support and accolades on their PharmFree initiative. I wonder if they know about the woo, or even care.
This thing definitely needs exposure and I'm glad to see the efforts of you and Kevin MD (who linked to both of our posts) in that direction.
Hank Barnes wrote:
Also, (c) it kills children.
Hank Barnes attempts to cite Starfield as evidence that conventional medicine is bad. The trouble is that Starfield`s paper was garbage, and in any event, her paper was only looking at adverse drug responses, not all that other stuff, which comes from other sources.
Starfield only managed to come up with a 106,000 annual fatalities estimate by including date that were over 30 years old. If she had stuck to post-1970 data, her numbers would have been more like 15,000 -- 20,000. The referees were really asleep at the switch on this one.
On the bright side, if it becomes widely known that the current generation of medical students is this credulous, the annoying parents who like to stealthily brag about "my kid the med student" will be effectively defanged.
I think maybe the instinct to classify CAM as legitimate comes from a noble place - a default assumption that a person or idea is worthy until proven otherwise. A good scientist, though, ought to start out from the reverse position.
They're just students, hopefully too busy learning the systems of the body to critically examine CAM's claims. I hope they'll wise up as their education progresses.
D. Wright - If you know of a link to some useful discussion of Starfield (2000), please pass it on. I tried a Google for "starfield jama 2000" and found that the article itself is (of course) for subscribers only, and all the linked discussion was by the usual charlatans, starting with mercola.com.
I rejected AMSA in the mid 70's for the same reasons you are perturbed by it now. Course I don't like the AMA much either, but for different reasons.
Anna, you are in the People's Republic of Portland. Expect more interesting revelations from the otherwise normal (for Portland) people you meet and work with there. They vote in droves and drive the local as well as Statewide politics.
Beware.
Keep Portland Weird!
The trouble is that Starfield`s paper was garbage, and in any event, her paper was only looking at adverse drug responses, not all that other stuff, which comes from other sources.
Plus it overlooks the basic fact of questioning how many of those incidents did NOT directly lead to the death of the patient or were in situations where the "error" had little or no impact on the patient outcome one way or the other.
I have some familiarity with this organization and similar movements within US medical schools that allow the promotion of CAM without 1) adequate revisitation of critical thinking skills and 2) oversight by appropriate medical school faculty. Most US med school CAM programs operate as some offshoot from the main department of medicine and there is little incentive for critical thinking faculty to be involved with the course material.
As a result, non-evidence-based programs proliferate on even the best medical school campuses because 1) they sometimes bring in actual clinical earnings, 2) faculty who oppose the programs are either too busy to get involved or think that association will stigmatize them, or 3) combatting non-rigorous CAM teaching falls low on the list of priorities of most medical school faculty members. I also fault members of some curriculum committees for not being as forcefully critical as they should be of what gets taught and who does the teaching.
Even when I teach herbal medicines, one of the more conceptually-acceptable and fact-based of the alt med practices, I am amazed by how many students just want me to talk about doses without even getting into a detailed of evaluation of whether the stuff works in the first place. Some are very disappointed when I tell them how few herbal medicines are actually supported by double-blind, placebo-controlled efficacy trials. However, facts are facts, and facts are not often what advocates want to know.
Hank Barnes, you are a troll. The issue is not how many people die BECAUSE of conventional medicine, but how many would have died WITHOUT it - and that is a much more frightening number. At least all but the most psychotic fringe of doctors agonise over the patients they lose through medical errors. Most of the prominent alties put the blame on the patient, or on conventional medicine. Big difference.
Orac: Bloody hell. And yet, the same problem is occurring here in Oz. Raw science - embryology, anatomy, histology, histopathology, physiology - is being cut back in order to shorten courses (both undergraduate and postgraduate-entry) and is often replaced by what my boss calls "touchy-feely" subjects. With this de-emphasis on basic medical sciences, it's no wonder that more than just a fringe of medical students/junior docs these days is becoming susceptible to being taken in by murderous bullshit.
Sadly, some of those gullible people are good friends of mine... :-(
"Although medically unproven, there is a wealth of anecdotal evidence as to the effectiveness of this approach."
That's a bit like going to buy a car and saying "I have no money, but I have a wealth of toothpicks"
The problem is the whole concept of CAM is a red herring. The only way to look at it is using a system like Dr Stephen (Quackwatch) Barrett describes: Medicine can be valid, experimental or dubious. Everything else is just politics.
I like the word "woo", as used here and on randi.org, and wish to incorporate it into my daily discourse. I wonder if Carlos Mencia's song "Dee Dee Dee" could be appropriately filked.
Another side effect is the push to create more doctors (especially in certain parts of the U.S.) causing med schools to consider reducing the number of years one spends in school from four to three. While some of that may be condensed clinical rotations (bad in and of itself) you may also see the basic science curriculum condensed, which means that future doctors may lack the scientific fundamentals to discern woo.
This is a straw scientist. If efficacy can be proven, a treatment will be used pending discovery of mechanism. Case in point: painkillers. Aspirin was developed from willow bark and used for decades before prostaglandins were even known to exist, much less known to be active in inflammation.
Another good piece in the New York Times -- To Catch a Deadly Germ supplements what Starfield was talking about. First sentence:
What kills more than five times as many Americans as AIDS? Hospital infections, which account for an estimated 100,000 deaths/year.
In my view, woo don't work -- but it's the height of hypocrisy for folks to wail about woo, while ignoring serious medical problems caused by doctors and hospitals.
100,000 deaths per year from infections is grossly negligent and dwarves by comparison, whatever wooers are doing with their bean curd enemas and mystic wrist rings.
Failure to address this problem probably breeds more woo, in fact.
HankBarnes
jre, I'm afraid I don't have a quick reference to a good discussion of Starfield's paper. I went to the rather drastic extreme of going to my local library and getting that issue of JAMA, and the ones where the responses appeared. There are occasional good threads on the matter, but they tend to be drowned out by the tsunamis of woo from the likes of Mercola.
Lazarou et al's paper on fatalities from adverse drug reactions is even worse, since the total number of deaths they really had to work with was: 5. Yep, five. From this, they extrapolated 100,000 deaths nationally per annum. The error bars on this are so large as to defy description.
Thanks, D!
I will need to do my homework, just as you have -- and a trip to the library won't kill me.
I feel particularly motivated to be fair to Starfield, because recent experience has given us several examples of scholarly studies that became political lightning rods and -- in my view, at least -- attracted more than their share of uninformed criticism.
Just doing a rough comparison of the numbers cited by Hank Barnes above and mortality data for 2003 - 2004, I see that the total is roughly 10% of all deaths; also that it it not at all obvious that Starfield's numbers for annual deaths by cause, as cited, can be reconciled with the CDC's numbers. From that, I suspect that the widely touted estimate of 220,000 "iatrogenic" deaths annually is a grotesque distortion of reality, motivated by the desire among some to show that the whole enterprise of medicine has done more harm than good -- and, consequently, that voodoo could do no worse.
But that's just me.
hankbarnes: Now you're relying on an opinion piece that doesn't even cite its source for that number (nor for any of the other claims)? At least it's from today, not something from 30 years ago. Even if that number is correct, it's a bit of a stretch to claim that doctors are causing those deaths. Failing to prevent, perhaps, but causing?
Gosh, I suppose we should just get rid of doctors all together to save all those lives... I mean, it's not like they save many other lives or anything. </sarcasm>
Ooh, some touchy folks. Umm, try not to blame the messenger, and try to address what Dr. Lazarou, Dr. Starfield and the NY Times are saying.
Some stooge wrote:
From that, I suspect that the widely touted estimate of 220,000 "iatrogenic" deaths annually is a grotesque distortion of reality,
So, why do you think the editors at the Journal of American Medical Association (JAMA) and the author (Dr. Starfield, PhD and MD at Johns Hopkins) are trying to distort reality?
HankB
The cynic in me surmizes that this may have more to do with AMSA members seeing that $29 billion industry (half of the entire Part B PFS!) with no FDA regulation, no DEA political interference, few if any malpractice suits, low practice expense, and little technical work required beyond a simple E/M workup and figured they were looking at easy money.
And y'know, from a purely economic perspective, I almost have to admire them. In economic terms they are certainly acting as rational actors...well, microeconomic terms, I suppose. The damage to the system as a whole would be unimaginable, but they might benefit as individuals for a brief period of time.
Does anyone know if the number of deaths by infection quoted above, is that the only cause of death? Or was the infection the final blow to a terminal cancer patient or someone with a chronic illness?
"And y'know, from a purely economic perspective, I almost have to admire them. In economic terms they are certainly acting as rational actors...well, microeconomic terms, I suppose. The damage to the system as a whole would be unimaginable, but they might benefit as individuals for a brief period of time."
Alas markets will often fail (sometimes spectacularly) in the presence of asymmetric information. Medicine is definitely an area where a bit of judicious regulation can do a lot of good. And I'm a big fan of free markets.
Ooh, some touchy folks. Umm, try not to blame the messenger, and try to address what Dr. Lazarou, Dr. Starfield and the NY Times are saying.
If the facts they're using are significant distortions of reality, then all of their other arguments hold less merit.
Hank, you are a notorious troll, and you know it as well as the rest of us.
Let's be crystal clear: the grotesque distortion of reality is yours, in trying to argue that the (very real) problems of managing errors and infection in the hospital setting should give comfort to those who think woo is equivalent to medicine. And, now that you bring it up, politically motivated smoke-blowing is not the equivalent of rational argument, either.
And I see that I am now out of troll food. You'll have to wait until my next trip to TrollSmart.
And I see that I am now out of troll food
You're probably out of brain food, too:)
Look, the main critique of woo is that the purveyors of said woo don't publish data in peer-reviewed journals. So, it is unknown whether the various bean-curd enemas and magnetic wrist thingys: (a) work or don't work or (b)help or harm.
That's a sound critique. I agree with it.
However, there are 2 papers in the peer-reviewed literature (both published in JAMA) that estimate: (a) 106,000 deaths/year from adverse drug reactions and (b) 220,000 deaths/year when you add unnecessary surgery, hospital infections and other stuff. (See Lazarou et al and Starfield)
So, to criticize woo purveyors for failing to provide real evidence of anything, while ignoring the evidence in the peer reviewed journals showing abundant problems with conventional medicine is: (a) myopically unscientific and (b)intellectually dishonest.
That is all.
HBarnes
Perhaps the problem is that there actually are studies on actual doctors... I wonder what they would look like if the same types of studies were done on various forms of "woo?" After all, you rarely hear about the different kind of testimonial, though I suspect that it's not because it is rare.
Does anyone know of any large scale studies of deaths caused by (perhaps through negligence) homeopathy, acupuncture, coffee enemas, etc.?
Still trying to work out what hospital cleanliness, deaths and the other stuff mentioned by Mr Barnes has to do with woo being taught as acceptable to the next generation of American doctors.
We can discuss those things another time, perhaps when the actual subject or something directly related is on the agenda.
And of the deaths mentioned: it doesn't appear they were *caused* by evidence medicine, it seems to be medical complications that don't directly have anything to do with medicine itself. Unless all hospital janitors are classed as doctors now?
Where medicine does have faults, it is completely untrue that criticising altie woo is either 'myopically unscientific' or 'intellectually dishonest'. We would be living in a very bizzarre world if scientists did not argue against quackery just because they themselves didn't have the answer to everything.
Orac wrote, "Indeed, even physicians of the 19th century, physicians like Oliver Wendell Holmes, could quite convincingly show why homeopathy is utter bullshit."
No, homeopathy is only the electromagnetic frequency imprint of bullshit.
One finds undiluted, full-strength bullshit in homeopathy's proponents.
Chinese traditional medicine (CTM) has lost two-thirds of its practitioners because China has access to evidence-based medical training-- essentially unavailable before the Revolution. Chairman Mao promoted CTM as much for its political message as for its supposed efficacy. The Cultural Revolution endorsed CMT in the same way it endorsed "traditional" law, science, art, philosophy, and so forth: as the means to separate out Western "contamination", and to purge dissonant (i.e., anti-Mao) voices.
Mao himself made a great public display of being treated by "barefoot doctors", but in private Mao used Western medical treatment for his health problems.
fantastic post, and a topic that needs a smack down. in the realm of healing we need evidence above all else.
Thanks Lucas, that thought had occurred to me this morning when I was at work. I smacked my head once it did; why was I wasting my time arguing about it when it's not relevant?
Hank, try comparing the net QALYs added by scientific medical interventions with the net QALYs added by 'alternative medicine'. If you don't agree that this is a fair comparison, please explain why.
And you are obviously poorly informed about the modern practice of hospital medicine. Doctors (and other staff) periodically conduct audits of recent patients' notes to check effectiveness of a particular intervention, and scan the current literature for new developments. You will be surprised to learn that treatment recommendations often change as a result.
Orac:
I just graduated from residency, having graduated from med school four years ago. At the time, there were altie classes available, but they were electives, and the only students who enrolled were the ones who were there for the social gathering. Of the medical students I interacted with during residency, none ever mentioned anything about TCM or CAM.
I think we should be scared about the future of medicine with this kind of crap being so strongly supported by the "AMA" of med students. I find it surprising though, because now that I'm in the "real world," I find more and more emphasis on evidence-based treatments. Even more so than in residency, where the good 'ol boy faculty's anecdotal evidence was the Word of God.
Interesting post.