Exposing quackery in medical education

Academic medical woo (maybe we should start calling it quackademic medicine) has, in recent weeks, received increased coverage in the blogosphere and beyond. I’m encouraged by this groundswell of interest. Medical education needs a good Flexnerian housecleaning. What better tribute could be paid to Abraham Flexner a century after his seminal report? If Flexner could see what’s happening in academic medicine today he would be appalled. He was not in sympathy with integrative medicine. Wikipedia has this to say about the impact of the Flexner Report:

Medical schools that offered training in various disciplines including eclectic medicine, physiomedicalism, naturopathy and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all complied with the Report or shut their doors.

(If you’re interested in primary sources read Chapter 10 of the original report where you’ll find some pretty harsh language concerning integrative medicine).

Soon after the Flexner Report and for decades thereafter medical education and practice gradually became more scientific, long before Guyatt and colleagues coined the term evidence based medicine. (I reviewed some of the history of twentieth century medicine’s scientific progress in a recent post here). Ironically, in fact, it was about the time the evidence based medicine movement was birthed in 1992 that pseudoscience under the rubric of complementary and alternative medicine was getting its foot in the door of medical schools. Since then medical education has turned its back on Flexner’s warnings and devolved from its scientific underpinnings.

If there’s any chance to expunge quackery promotion from academic medicine it has to start with exposure. Recent blog and media reactions have been modestly encouraging. Here’s a roundup of the past few weeks along with some observations.

Kevin, in typical pithy style, nailed it by pointing out that the infiltration of woo is weakening the credibility of academic medicine and damaging the evidence based medicine movement. His post was titled A step backward for academic medicine. Indeed academic medicine is moving backward, but I would characterize it as more of a slide down a slippery slope, a slide that’s picking up speed.

Dr. Wallace Sampson’s rich posts from the last two weeks on the new Science Based Medicine blog examine the origins and consequences of the infiltration of pseudoscience (which he, like Flexner, terms sectarianism). He cites several examples including a recent melding of pseudoscience and mainstream medicine at Harvard University and its astonishingly uncritical coverage in, of all places, Science Magazine.

Sampson documents a broad and uncritical societal acceptance of CAM at a time when a self-doubting and overly self-critical medical establishment was vulnerable, succinctly pointing out that “the press wowed and academics cowed…”

In a post yesterday Orac noted increased media attention to CAM which, unfortunately, ranges from promotional to only partially critical. The latter article, though, from U.S. News and World Report (USNWR), made this perceptive observation: “The setting for the unorthodox therapy—an academic medical center—would have been startling just five or 10 years ago.” Yes, there was a time, a decade or two ago, when the promoters of quackery would have been laughed off the podium of most medical school classrooms.

The USNWR quoted Andrew Weil as advocating an inconsistent evidentiary standard for medical claims, a “sliding scale” of evidence in which treatments with lower risk would require an easier standard of proof. Orac notes the logical extension of that argument by pointing out that true homeopathic remedies, consisting of only water, would require no proof at all. (Maybe the burden of proof would decrease in proportion to the number of dilutions of the remedy!). On its face that argument might have some appeal. After all, if it’s harmless why question it? Aside form the obvious theoretical objection (that all scientific claims should require rigorous scientific proof) there are practical consequences to that argument which become apparent on closer examination.

The article also provided examples of academic woo that even Orac wasn’t aware of. No doubt he’ll be updating his Academic Woo Aggregator soon.

Finally, let me mention (again) the latest Medscape Roundtable in which colleagues and I debated the issue of CAM teaching in medical school. This was a unique opportunity to take the issue (apologies to Dr. Anonymous) “beyond the blog” to the vast audience of Medscape.

A recurring question was raised in many of the postings: what’s driving the infusion of woo into academic medicine? One obvious factor is money. Consumer demand for woo is high and patients are willing to pay out of pocket for it. There being no scientific basis for most of these therapies, a desire to take patients’ money may be reason enough for some folks on the administrative side of academic medical institutions.

But there are other, perhaps less well appreciated reasons. One is irrational anti-corporate hatred and the growing popular distrust of the pharmaceutical industry, leading many to seek “alternatives.” It doesn’t take extreme googling to document numerous examples.

Other reasons include political correctness and postmodernism which I discussed at some length here. Wallace Sampson and Kimball Atwood IV, in a commentary in the Medical Journal of Australia, describe the effects of postmodernism with its “multiple ways of knowing” on medicine:

In the postmodern catechism, facts and science are artefacts of social constructions, and modern medicine expresses political hegemony over other, subjugated forms of healing, such as naturopathy and homoeopathy.

Postmodern CAM also tolerates contradiction without need for resolution through reason and experiment, resulting in a medical pluralism. Various “schools” and philosophies of healing — each inconsistent with the others, such as chiropractic, homoeopathy, orthomolecular medicine, and traditional Chinese medicine — create a scientific multiculturalism. Implausible proposals and claims become tolerable and comfortable, and the CAM advocate’s burden of proof is shifted to disproof by the science community, which that community accepts without major objection.

Finally, and somewhat paradoxically, the rise in unfounded CAM modalities may be an unintended consequence of the EBM movement. EBM advocates devalue scientific rationale and physiologic plausibility. (That reflects a very popular distortion, not a core principle, of EBM). Again, from the Medical Journal of Australia paper:

Evidence-based medicine (EBM), relying on results of randomised trials, should be a bulwark against the Absurd. However, the heterogeneity of clinical trial methods and designs, differing population bases, and varying endpoints often result in heterogeneity of outcomes. This has precluded systematic reviews of CAM methods from defining a line of inefficacy. EBM also does not include plausibility or consistency with basic science in its methods and reviews, leaving each to physician and patient interpretation.

In another editorial Dr. Sampson further laments the distortion of EBM leading to uncritical acceptance of implausible research claims:

The second is a paradoxical consequence of "evidence-based medicine" (EBM). EBM, in the form of RCTs and their systematic reviews (SRs), is a means for accumulating and ranking data. EBM is not a means for interpreting the significance of the data. Significance depends in part on plausibility. EBM is independent of physiology and ignores plausibility.

Plausibility depends on prior reliable observations, physical and chemical laws, pharmacological principles, and advocates' economic and legal misadventures. The
National Center for Complementary and Alternative Medicine spends $100 million/year on implausible research and training grants. In performing RCTs on implausible proposals, clinical research has taken a wrong turn and departed from rationality.

So where’s it all going? Are medical schools really becoming Hogwarts schools of witchcraft and wizardry? Maybe so! If we’re not there yet we’re headed there with increasing velocity. The boosters of CAM education are organized. Many academic medical centers have formed a Consortium for Integrative Medicine. The Consortium is supported by big money and seeks to promote integrative medicine. A careful reading of the pages of their website suggests an agenda for medical education based on experiential and promotional learning rather than critical analysis.

Even more disturbing is medical student activism for non-evidence based and implausible CAM. The American Medical Student Association (AMSA), the largest (some 68,000 strong) and best organized medical student society in the U.S., suggests, through its various publications, chelation therapy for multiple ailments, TCM, therapeutic touch, qigong and fasting. These students are our future academic leaders and even now are participating in CAM curriculum development at some schools.

What can be done about it? Although the rising chorus of voices against pseudoscientific medical education is encouraging the chorus is small, and the situation, from where I sit, is not good. At this late point nothing short of all out war on quackademic medicine will be effective. It can be done. It’s not unprecedented. Just look at the lobby against deceptive pharmaceutical company marketing. They have web sites. They’re making documentary films. They’re writing books. They have visibility. We need to be similarly organized.