Critical thinking and the scientific method in medical education

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 Insolence⢠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.