Continuing med education
‘We know little about the effect of diet on health. That’s why so much is written about it’. That is the title of a post in which I advocate the view put by John Ioannidis that remarkably little is known about the health effects if individual nutrients. That ignorance has given rise to a vast industry selling advice that has little evidence to support it.
The 2016 Conference of the so-called "College of Medicine" had the title "Food, the Forgotten Medicine". This post gives some background information about some of the speakers at this event. I’m sorry it appears to be too ad hominem, but the only way to judge the meeting is via the track record of the speakers.
Quite a lot has been written here about the "College of Medicine". It is the direct successor of the Prince of Wales’ late, unlamented, Foundation for Integrated Health. But unlike the latter, its name is disguises its promotion of quackery. Originally it was going to be called the “College of Integrated Health”, but that wasn’t sufficently deceptive so the name was dropped.
For the history of the organisation, see
The conference programme (download pdf) is a masterpiece of bait and switch. It is a mixture of very respectable people, and outright quacks. The former are invited to give legitimacy to the latter. The names may not be familiar to those who don’t follow the antics of the magic medicine community, so here is a bit of information about some of them.
The introduction to the meeting was by Michael Dixon and Catherine Zollman, both veterans of the Prince of Wales Foundation, and both devoted enthusiasts for magic medicne. Zollman even believes in the battiest of all forms of magic medicine, homeopathy (download pdf), for which she totally misrepresents the evidence. Zollman works now at the Penny Brohn centre in Bristol. She’s also linked to the "Portland Centre for integrative medicine" which is run by Elizabeth Thompson, another advocate of homeopathy. It came into being after NHS Bristol shut down the Bristol Homeopathic Hospital, on the very good grounds that it doesn’t work.
Now, like most magic medicine it is privatised. The Penny Brohn shop will sell you a wide range of expensive and useless "supplements". For example, Biocare Antioxidant capsules at £37 for 90. Biocare make several unjustified claims for their benefits. Among other unnecessary ingredients, they contain a very small amount of green tea. That’s a favourite of "health food addicts", and it was the subject of a recent paper that contains one of the daftest statistical solecisms I’ve ever encountered
"To protect against type II errors, no corrections were applied for multiple comparisons".
If you don’t understand that, try this paper.
The results are almost certainly false positives, despite the fact that it appeared in Lancet Neurology. It’s yet another example of broken peer review.
It’s been know for decades now that “antioxidant” is no more than a marketing term, There is no evidence of benefit and large doses can be harmful. This obviously doesn’t worry the College of Medicine.
Margaret Rayman was the next speaker. She’s a real nutritionist. Mixing the real with the crackpots is a standard bait and switch tactic.
Eleni Tsiompanou, came next. She runs yet another private "wellness" clinic, which makes all the usual exaggerated claims. She seems to have an obsession with Hippocrates (hint: medicine has moved on since then). Dr Eleni’s Joy Biscuits may or may not taste good, but their health-giving properties are make-believe.
Andrew Weil, from the University of Arizona
gave the keynote address. He’s described as "one of the world’s leading authorities on Nutrition and Health". That description alone is sufficient to show the fantasy land in which the College of Medicine exists. He’s a typical supplement salesman, presumably very rich. There is no excuse for not knowing about him. It was 1988 when Arnold Relman (who was editor of the New England Journal of Medicine) wrote A Trip to Stonesville: Some Notes on Andrew Weil, M.D..
“Like so many of the other gurus of alternative medicine, Weil is not bothered by logical contradictions in his argument, or encumbered by a need to search for objective evidence.”
This blog has mentioned his more recent activities, many times.
Alex Richardson, of Oxford Food and Behaviour Research (a charity, not part of the university) is an enthusiast for omega-3, a favourite of the supplement industry, She has published several papers that show little evidence of effectiveness. That looks entirely honest. On the other hand, their News section contains many links to the notorious supplement industry lobby site, Nutraingredients, one of the least reliable sources of information on the web (I get their newsletter, a constant source of hilarity and raised eyebrows). I find this worrying for someone who claims to be evidence-based. I’m told that her charity is funded largely by the supplement industry (though I can’t find any mention of that on the web site).
Stephen Devries was a new name to me. You can infer what he’s like from the fact that he has been endorsed byt Andrew Weil, and that his address is "Institute for Integrative Cardiology" ("Integrative" is the latest euphemism for quackery). Never trust any talk with a title that contains "The truth about". His was called "The scientific truth about fats and sugars," In a video, he claims that diet has been shown to reduce heart disease by 70%. which gives you a good idea of his ability to assess evidence. But the claim doubtless helps to sell his books.
Prof Tim Spector, of Kings College London, was next. As far as I know he’s a perfectly respectable scientist, albeit one with books to sell, But his talk is now online, and it was a bit like a born-again microbiome enthusiast. He seemed to be too impressed by the PREDIMED study, despite it’s statistical unsoundness, which was pointed out by Ioannidis. Little evidence was presented, though at least he was more sensible than the audience about the uselessness of multivitamin tablets.
Simon Mills talked on “Herbs and spices. Using Mother Nature’s pharmacy to maintain health and cure illness”. He’s a herbalist who has featured here many times. I can recommend especially his video about Hot and Cold herbs as a superb example of fantasy science.
Annie Anderson, is Professor of Public Health Nutrition and
Founder of the Scottish Cancer Prevention Network. She’s a respectable nutritionist and public health person, albeit with their customary disregard of problems of causality.
Patrick Holden is chair of the Sustainable Food Trust. He promotes "organic farming". Much though I dislike the cruelty of factory farms, the "organic" industry is largely a way of making food more expensive with no health benefits.
The Michael Pittilo 2016 Student Essay Prize was awarded after lunch. Pittilo has featured frequently on this blog as a result of his execrable promotion of quackery -see, in particular, A very bad report: gamma minus for the vice-chancellor.
Nutritional advice for patients with cancer. This discussion involved three people.
Professor Robert Thomas, Consultant Oncologist, Addenbrookes and Bedford Hospitals, Dr Clare Shaw, Consultant Dietitian, Royal Marsden Hospital and Dr Catherine Zollman, GP and Clinical Lead, Penny Brohn UK.
Robert Thomas came to my attention when I noticed that he, as a regular cancer consultant had spoken at a meeting of the quack charity, “YestoLife”. When I saw he was scheduled tp speak at another quack conference. After I’d written to him to point out the track records of some of the people at the meeting, he withdrew from one of them. See The exploitation of cancer patients is wicked. Carrot juice for lunch, then die destitute. The influence seems to have been temporary though. He continues to lend respectability to many dodgy meetings. He edits the Cancernet web site. This site lends credence to bizarre treatments like homeopathy and crystal healing. It used to sell hair mineral analysis, a well-known phony diagnostic method the main purpose of which is to sell you expensive “supplements”. They still sell the “Cancer Risk Nutritional Profile”. for £295.00, despite the fact that it provides no proven benefits.
Robert Thomas designed a food "supplement", Pomi-T: capsules that contain Pomegranate, Green tea, Broccoli and Curcumin. Oddly, he seems still to subscribe to the antioxidant myth. Even the supplement industry admits that that’s a lost cause, but that doesn’t stop its use in marketing. The one randomised trial of these pills for prostate cancer was inconclusive. Prostate Cancer UK says "We would not encourage any man with prostate cancer to start taking Pomi-T food supplements on the basis of this research". Nevertheless it’s promoted on Cancernet.co.uk and widely sold. The Pomi-T site boasts about the (inconclusive) trial, but says "Pomi-T® is not a medicinal product".
There was a cookery demonstration by Dale Pinnock "The medicinal chef" The programme does not tell us whether he made is signature dish "the Famous Flu Fighting Soup". Needless to say, there isn’t the slightest reason to believe that his soup has the slightest effect on flu.
In summary, the whole meeting was devoted to exaggerating vastly the effect of particular foods. It also acted as advertising for people with something to sell. Much of it was outright quackery, with a leavening of more respectable people, a standard part of the bait-and-switch methods used by all quacks in their attempts to make themselves sound respectable. I find it impossible to tell how much the participants actually believe what they say, and how much it’s a simple commercial drive.
The thing that really worries me is why someone like Phil Hammond supports this sort of thing by chairing their meetings (as he did for the "College of Medicine’s" direct predecessor, the Prince’s Foundation for Integrated Health. His defence of the NHS has made him something of a hero to me. He assured me that he’d asked people to stick to evidence. In that he clearly failed. I guess they must pay well.
Stolen from badscience.net
Peter Medawar, the eminent biologist, in his classic book Advice to a Young Scientist, said this.
“Exaggerated claims for the efficacy of a medicament are very seldom the consequence of any intention to deceive; they are usually the outcome of a kindly conspiracy in which everybody has the very best intentions. The patient wants to get well, his physician wants to have made him better, and the pharmaceutical company would have liked to have put it into the physician’s power to have made him so. The controlled clinical trial is an attempt to avoid being taken in by this conspiracy of good will.”
There was a lot of truth in that 1979, towards the end of the heyday of small molecule pharmacology. Since then, one can argue, things have gone downhill.
First, though, think of life without general anaesthetics, local anaesthetics, antibiotics, anticoagulants and many others. They work well and have done incalculable good. And they were developed by the drug industry.
But remember also that remarkably little is known about medicine. There are huge areas in which neither causes nor cures are known. Treatments for chronic pain, back problems, many sorts of cancer and almost all mental problems are a mess. It just isn’t known what to do. Nobody is to blame for this. Serious medical research has been going on for little more than 60 years, and it turns out to be very complicated. We are doing our best, but are still ignorant about whole huge areas. That leads to a temptation to make things up. Clutching at straws is very evident when it comes to depression, pain and Alzheimer’s disease, among others.
In order to improve matters, one essential is to do fair tests on treatments that we have. Ben Goldacre’s book is a superb account of how this could be done, and how the process of testing has been subverted for commercial gain and to satisfy the vanities of academics.
Of course there is nothing new in criticisms of Big Pharma. The huge fines levied on them for false advertising are well known. The difference is that Goldacre’s book explains clearly what’s gone wrong in great detail, documents it thoroughly, and makes concrete suggestions for improving matters.
Big Pharma has undoubtedly sometimes behaved appallingly in recent years. Someone should be in jail for crimes against patients. They have behaved in much the same way that bankers have. In any huge globalised industry it is always possible to blame someone in another department for the dishonesty. But they aren’t the only people to blame. None of the problems could have arisen with the complicity of academics, universities, and a plethora of regulatory agencies and professional bodies.
The biggest scandal of all is missing data (chapter 1). Companies, and sometmes academics, have suppressed of trials that don’t favour the drugs that they are trying to sell. The antidepressant drug, reboxetine, appeared at first to be good. It had been approved by the Medicines and Healthcare products Regulatory Agency (MHRA) and there was at least one good randomized placebo-controlled trial (RCT) showing it worked. But it didn’t. The manufacturer didn’t provide a complete list of unpublished trials when asked for them. After much work it was found in 2010 that, as well as the published, favourable trial, there were six more trials which had not been published and all six showed reboxetine to be no better than placebo . In comparisons with other antidepressant drugs three small studies (507 patients) showed reboxetine to be as good as its competitors. These were published. But it came to light that data on 1657 patients had never been published and these showed reboxetine to be worse than its rivals.
When all the data for the SSRI antidepressants were unearthed (Kirsch et al., 2008) it turned out that they were no better than placebo for mild or moderate depression. This selective suppression of negative data has happened time and time again. It harms patients and deceives doctors, but, incredibly, it’s not illegal.
Disgracefully, Kirsch et al. had to use a Freedom of Information Act request to get the data from the FDA.
“The output of a regulator is often simply a crude, brief summary: almost a ‘yes’ or ‘no’ about side effects. This is the opposite of science, which is only reliable because everyone shows their working, explains how they know that something is effective or safe, shares their methods and their results, and allows others to decide if they agree with the way they processed and analysed the data.”
“the NICE document discussing whether it’s a good idea to have Lucentis, an extremely expensive drug, costing well over £ 1,000 per treatment, that is injected into the eye for a condition called acute macular degeneration. As you can see, the NICE document on whether this treatment is a good idea is censored. Not only is the data on the effectiveness of the treatment blanked out by thick black rectangles, in case any doctor or patient should see it, but absurdly, even the names of some trials are missing, preventing the reader from even knowing of their existence, or cross referencing information about them.Most disturbing of all, as you can see in the last bullet point, the data on adverse events is also censored.”
The book lists all the tricks that are used by both industry and academics. Here are some of them.
- Regulatory agencies like the MHRA, the European Medicines Agency (EMA) and the US Food and Drugs Administration (FDA) set a low bar for approval of drugs.
- Companies make universities sign gagging agreements which allow unfavourable results to be suppressed, and their existence hidden.
- Accelerated approval schemes are abused to get quick approval of ineffective drugs and the promised proper tests often don’t materialise
- Disgracefully, even when all the results have been given to the regulatory agencies (which isn’t always). The MHRA, EMA and FDA don’t make them public. We are expected to take their word.
- Although all clinical trials are meant to be registered before they start, the EMA register, unbelievably, is not public. Furthermore there is no check that the results if trials ever get published. Despite mandates that results must be published within a year of finishing the trial, many aren’t. Journals promise to check this sort of thing, but they don’t.
- When the results are published, it is not uncommon for the primary outcome, specified before it started, to have been changed to one that looks like a more favourable result. Journals are meant to check, but mostly don’t.
- Companies use scientific conferences, phony journals, make-believe “seed trials” and “continuing medical education” for surreptitious advertising.
- Companies invent new diseases, plant papers to make you think you’re abnormal, and try to sell you a “cure”. For example, female sexual dysfunction , restless legs syndrome and social anxiety disorder (i.e. shyness). This is called disease-mongering, medicalisation or over-diagnosis. It’s bad.
- Spin is rife. Companies, and authors, want to talk up their results. University PR departments want to exaggerate benefits. Journal editors want sensational papers. Read the results, not the summary. This is universal (but particularly bad in alternative medicine).
- Companies fund patient groups to lobby for pills even when the pills are known to be ineffective. The lobby that demanded that Herceptin should be available to all on the breast cancer patients on the NHS was organised by a PR company working for the manufacturer, Roche. But Herceptin doesn’t work at all in 80% of patients and gives you at best a few extra months of life in advanced cases.
- Ghostwriting of papers is serious corruption. A company writes the paper and senior academics appear as the authors, though they may never have seen the original data. Even in cases where academics have admitted to lying about whether they have seen the data, they go unpunished by their universities. See for example, the case of Professor Eastell.
- By encouraging the funding of “continuing medical education” by companies, the great and the good of academic medicine have let us down badly.
This last point is where the book ends, and it’s worth amplification.
“So what have the great and good of British medicine done to help patients, in the face of this endemic corruption, and these systematic flaws? In 2012, a collaborative document was produced by senior figures in medicine from across the board, called ‘Guidance on Collaboration Between Healthcare Professionals and the Pharmaceutical Industry’. This document was jointly approved by the ABPI, the Department of Health, the Royal Colleges of Physicians, Nursing, Psychiatrists, GPs, the Lancet, the British Medical Association, the NHS Confederation, and so on. ”
“It contains no recognition of the serious problems we have seen in this book. In fact, quite the opposite: it makes a series of assertions about them that are factually incorrect.”
“It states that drug reps ‘can be a useful resource for healthcare professionals’. Again, I’m not sure why the Royal Colleges, the BMA, the Department of Health and the NHS Confederation felt the need to reassert this to the doctors of the UK, on behalf of industry, when the evidence shows that drug reps actively distort prescribing practices. But that is the battle you face, trying to get these issues taken seriously by the pinnacle of the medical establishment.”
This is perhaps the most shameful betrayal of all. The organisations that should protect patients have sold them out.
You may have been sold out by your “elders and betters”, but you can do something. The “What to do” sections of the book should be produced as a set of flash cards, as a reminder that matters can be improved.
It is shameful that this book was not written by a clinical pharmacologist, or a senior doctor, or a Royal College, or a senior academic. Why has the British Pharmacological Society said nothing?
It is shameful too that this book was not written by one of the quacks who are keen to defend the $60 billion alternative medicine industry (which has cured virtually nothing) and who are strident in their criticism of the 600 billion dollar Pharma industry. They haven’t done the work that Goldacre has to analyse the real problems. All they have done is to advocate unfair tests, because that is the only sort their treatments can pass.
It’s weird that medicine, the most caring profession, is more corrupt than any other branch of science. The reason, needless to say, is money. Well, money and vanity. The publish or perish mentality of senior academics encourages dishonesty. It is a threat to honest science.
Goldacre’s book shows the consequences: harm to patients and huge wastage of public money.
7 October, 2012, The Observer
"I think it’s really disappointing that nobody, not the Royal Colleges, the Academy of Medical Sciences, the British Pharmacological Society, the British Medical Association, none of these organisations have stood up and said: selective non-publication of unflattering trial data is research misconduct, and if you do it you will be booted out. And I think they really urgently should."
My original piece on Integrative Baloney@Yale was posted on May 16th, after I got back from a visit there. The talk I gave there included a short video. My movie, Integrative baloney@Yale, was made entirely from clips taken from Yale’s own YouTube movies which showed something approaching three hours of its “1st Annual Scientific [sic] symposium”, entitled “Complementary and Alternative Medicine: Evidence for Integration”. I had merely interspersed a few titles to show the worst scientific absurdities of that rather pathetic event. YouTube removed the movie last week.
You can download the movie here [15.8 Mb, wmv file].
It should soon reappear on YouTube (actually it took over a month and several reminders, but eventually they kept their word in the end).
Yale’s lawyers had written to YouTube, to have my movie removed. I guess if you have no evidence, all you can do is resort to law to suppress the views of those who have the temerity to point out that the emperor is naked. Last week it was New Zealand Chiropractors’ Association Inc. This week the rather more substantial Yale University. We live in interesting times.
This is what I got on 15th August.
This is to notify you that we have removed or disabled access to the following material as a result of a third-party notification by Yale University, Yale School of Medicine (CME) claiming that this material is infringing:
Integrative baloney@Yale: http://uk.youtube.com/watch?v=HEl2fhfGBdI
Please Note: Repeated incidents of copyright infringement will result in the deletion of your account and all videos uploaded to that account. In order to prevent this from happening
If you clicked on the link you saw
“This video is no longer available due to a copyright claim by Yale University, Yale School of Medicine (CME)”
It seems that Yale’s Continuing Medical Education (CME) department was responsible.
Of course Yale is correct. I expect they own the copyright of their original movies, but they are not what I posted. I would argue that selecting 6 minutes from a 3 hour original amounts to “fair quotation”, no different from when one cites a short passage from somebody else’s book or paper. Perhaps Yale was just a bit jealous that my movie was getting viewed a lot more times than theirs. Or perhaps they were a bit peeved that a Google search for “Yale Integrative Medicine” produced my movie as #2 (add the word movie and I was #1).
My movie seems to me to be fair comment from someone who is a pharmacologist by trade. Apparently it didn’t seem that way to the apparatchiks of Yale Medical School, who seem to think that academic arguments should be settled by paying lawyers to suppress views they don’t like, rather than by rational discussion.
It’s interesting that the three hours of Yale’s own movie have also vanished from YouTube. Could that be because they realise that the remarks made at the meeting are so embarrassing intellectually that it would be better not to make them public? Actually, no.
What does Yale CME say?
Rather than publishing this straight away, I thought it better to delve a bit further into what had happened. I lodged an appeal with YouTube and I wrote to Ronald J. Vender, MD (Associate Dean, YSM Clinical Affairs, CMO, Yale Medical Group, Medical Director, Yale CME ). The outcome was rather interesting.
First, it turned out that the original posting of the three hours of the symposium proceedings on YouTube was itself unauthorised, which is why it suffered the same fate as my movie.
Dr Vender told me that he is new to the job, and didn’t know about the incident. What’s more surprising, he said he “did not know an Integrative Program even existed at Yale”. That does seem a bit odd indeed for an Associate Dean of Clinical Affairs.
However, Dr Vender turned out to be a very reasonable man,.After some amiable correspondence over the weekend, it took him only a day and a half to sort the matter out. After talking to Yale’s attorney, he wrote on 19th August, thus
“The University attorney believes that there is in fact a difference between the initial unauthorized filming of an entire conference as opposed to quoting from that conference. Therefore, she has agreed to withdraw the injunction that has been imposed on your use of the material. YouTube will be contacted.”
That’s good for me, but it isn’t the main thing. The movie would doubtless have been seen by more people if Yale had tried to maintain the ban. Much more impressively, Dr Vender also said
“As for this particular program, I will be speaking with Dr Belitsky and the program directors to encourage them to adopt a more critical view of the scientific basis for claims made by proponents of CAM. They will also be encouraged to develop a future program that includes faculty who have opposing points of view.”
It remains to be seen what actually happens, but so far, so good.
The removal of the original videos of the meeting is understandable because they were pretty embarrassing to Yale. But can that be the real reason? I was told that it is simply because their posting was “unauthorised”. But Yale Continuing Medical Education still boasts about the meeting on their own web site. They describe the meeting as “successful”, but if they are so proud of it, why remove the video from YouTube whether it was authorised or not? We are told
“The symposium, accredited for 7.5 AMA PRA Category 1 Credits, began what is hoped to be a long tradition at the Yale School of Medicine.”
They give credits for such miseducation?
Dr Katz’s phrase “we need a more fluid concept of evidence” now gets about 148 hits in Google, since I first helped him to publicise it.
Two of the six “learning objectives” that Yale CME lists for this symposium are particularly revealing.
- Describe therapeutic benefits and recent scientific evidence supporting a wide range of safe and practical complementary treatments, including acupuncture, massage, yoga, meditation, nutrition and exercise
- Identify and discuss barriers to CAM use, practice and research, as well as propose ways of overcoming these barriers
‘Describe the evidence supporting complementary treatments’? But don’t on any account describe the much more substantial evidence that does not support them? A question (or “learning objective”) put in this loaded way is the very antithesis of education.
Equally the second ‘learning objective’ carries with it the assumption that CAM works, otherwise why would anyone want to overcome the barriers to it?
This is indoctrination, not education. It betrays everything that a university should stand for.
Let’s hope the new head of CME, the admirable Dr Vender, succeeds in doing something about it
Success!. Well I think it is success. On 26 November 2008, the admirable Dr Vender wrote to me as follows.
“I do not know if another CAM/Integrative Medicine program is planned at Yale. However, based on the new ACCME standards, this program does not fulfil the standards for receiving CME accreditation (by my interpretation of the standards). At least one of last year’s program directors has been notified already.”