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David Katz

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Reply to David Katz.

The Atlantic is an American magazine founded (as The Atlantic Monthly) in Boston, Massachusetts, in 1857. It is a literary and cultural magazine with a very distinguished history. Its contributors include Mark Twain and Martin Luther King. So it was pretty exciting to be asked to write something for it, even with a 12 hour deadline.

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Sadly though, in recent years, the coverage of science in The Atlantic has been less than good The inimitable David Gorski has explained the problem in Blatant pro-alternative medicine propaganda in The Atlantic. The immediate cause of the kerfuffle was the publication of an article, The Triumph of New-Age Medicine. It was written by a journalist, David Freedman. It is very long and really not very good. It has been deconstructed also by Steven Novella.

Freedman’s article is very long, but it boils down to saying I know it doesn’t work but isn’t it nice. The article was followed up with Fix or Fraud: a ‘debate’., The debate is rather disappointing. It suffers from the problem, not unknown at the BBC, of thinking that ‘balance’ means giving equal time to people who think the earth is flat as it gives to people who think it is a oblate spheroid. The debate consists of 800 word contributions from seven people, six of whom are flat earthers, and one of which is very good. Try Steven Salzberg, A ‘triumph’ of hype over reality for some real sense. One of the flat earthers is director of a National Institutes of Health institute, NCCAM.

And this is a magazine that published not only Mark Twain, but Abraham Flexner, the man who, in 1910, put US medical education on a firm scientific footing, You can read Flexner in their archive. Mark Twain said

[A reply to letters recommending remedies]:

Dear Sir (or Madam):–I try every remedy sent to me. I am now on No. 67. Yours is 2,653. I am looking forward to its beneficial results. – quoted in My Father Mark Twain, by Clara Clemens

and

"allopathy is good for the sane and homeopathy for the insane"

So here is the piece, produced rather rapidly, for the debate. This is the original unedited version, slightly longer than appears in The Atlantic.

The title for The Atlantic piece, America, Land of the Health Hucksters, was theirs not mine. There is no shortage of health hucksters in the UK. but at least they mostly haven’t become as embedded within univerities and hospitals as much as in the USA.

David Freeman’s article, “The Triumph of New Age Medicine” starts by admitting that most alternative treatments don’t work, and ends by recommending them.  He takes a lot more words to say it, but that seems a fair synopsis.  It is the sort of thing you might expect in a cheap supermarket magazine, not in Atlantic.

The article is a prime example of rather effective sales technique, much beloved of used car salesmen and health hucksters. It’s called bait and switch.

It’s true that medicine can’t cure everything. That’s hardly surprising given that serious research has been going on for barely 100 years, and it turns out that the humans are quite complicated.  But the answer to the limitations of medicine is not to invent fairy stories, which is what the alternative medicine industry does.  There is no sensible option but to keep the research going and to test its results honestly.  It’s sad but true that Big Pharma has at times corrupted medicine, by concealing negative results.  But that corruption has been revealed by real scientists, not by health hucksters.  In the end, science is self-correcting and the truth emerges.  Health hucksters, on the other hand, seem incapable of giving up their beliefs whatever the evidence says.

The idea of patient-centered care is fashionable and care is great, if you can’t cure.  But there’s a whole spectrum in the wellbeing industry, from serious attempts to make people happier, to the downright nuts.  The problem is that caring for patients make a very good bait, and the switch to woo tends to follow not far behind.

I write from the perspective of someone who lives in a country that achieves health care for all its citizens at half the cost of the US system, and gets better outcomes in life expectancy and infant mortality. The view from outside is that US medicine rather resembles US religion. It has been taken over by fundamentalists who become very rich by persuading a gullible public to believe things that aren’t true.

One of Freedman’s problems is, I think, that he vastly overestimates the power of the placebo effect.  It exists, for sure, but in most cases, it seems to be small, erratic and transient.  Acupuncture is a good example.  It’s quite clear now that real acupuncture and sham acupuncture are indistinguishable, so it’s also quite clear that the ‘principles’ on which it’s based are simply hokum.  If you do a non-blind comparison of acupuncture with no acupuncture, there is in some trials (not all) a small advantage for the acupuncture group.  But it is too small to be of much benefit to the patient.

By far the more important reason why ineffective voodoo like acupuncture appears to work is the “get better anyway” effect (known technically as regression to the mean).  You take the needles or pills when you are at your worst, the next day you feel better.  It’s natural to attribute the fact that you feel better to the needles or pills, when all you are seeing is natural fluctuations in the condition.  It’s like Echinacea will cure your cold in only seven days when otherwise it would have taken a week.

If the article itself was naïve and uncritical, the follow up was worse. It is rather surprising to me that a magazine like Atlantic should think it worth printing an advertorial for Andrew Weil’s business.

Surely, though, Josephine Briggs, as director of an NIH institute is more serious?  Sadly, no.  Her piece is a masterpiece of clutching at straws. The fact is that her institute has spent over $ 2 billion of US taxpayers’ money and, for all that money it has produced not a single useful treatment.  All that NCCAM has done is to show that several things do not work, something we pretty much knew already. If I were a US taxpayer, I’d be somewhat displeased by that. It should be shut down now.

At first sight Dean Ornish sounds more respectable.  He bases his arguments on diet and life style changes, which aren’t alternative at all.  He’s done some research too.  The problem is that it’s mostly preliminary and inconclusive research, on the basis of which he vastly exaggerates the strength of the evidence for what can be achieved by diet alone. It’s classical bait and switch again.  The respectable, if ill-founded, arguments get you the foot in the door, and the woo follows later.

This is all very sad for a country that realized quite early that the interests of patients were best served by using treatments that had been shown to work. The Flexner report of 1910 led the world in the rational education of physicians. But now even places like Yale and Harvard peddle snake oil to their students through their "integrative medicine" departments. It’s hard to see why the USA is in the vanguard of substituting wishful thinking for common sense and reason.

The main reason, I’d guess, is money. Through NCCAM and the Bravewell Collaborative, large amounts of money have been thrown to the winds and businesses like Yale and Harvard have been quick to abandon their principles and grab the money. Another reason for the popularity of alternative medicine in parts of academia is that it’s a great deal easier to do ‘science’ when you are allowed to make up the answers. The "integrative medicine" symposium held at Yale in 2008 boggled the mind. Dr David Katz listed a lot of things he’d tried and which failed to work, His conclusion was not that they should be abandoned, but that we needed a "more fluid concept of evidence".  You can see it on YouTube,

Senator Tom Harkin’s promotion of NCCAM has done for the U.S. reputation in medicine what Dick Cheney did for the U.S. reputation in torture. It is hard to look at the USA from outside without thinking of the decline and fall of the Roman Empire.

One had hoped that era was over with the election of Obama, but the hucksters won’t give up without a fight. They are making too much money to do that.

Follow-up

The comments that appeared in The Atlantic on this piece were mostly less than enlightening -not quite what one expected of an intellectual magazine. Nevertheless I tried to answer all but the plain abusive comments.

More interesting, though, was an editorial by Jennie Rothenberg Gritz, the Atlantic Senior Editor who asked me to contribute. The Man Who Invented Medical School. It picked up on my mention of Abraham Flexner, and his famous 1910 report [download from Carnegie Foundation] which first put US medial education on a form rational footing. based on science. Now, 100 years later that’s being unpicked both in the USA and here. ms Gritz seemed to think that Flexner would have approved of Dean Ornish. In a response I begged to differ. I’m pretty sure that Felxner would have been furious of he could have seen the reecent march of quackademia, particularly, but not exclusively, in the USA. It is exactly the sort of thing his report set out, successfully, to abolish. He wrote, for example,

“the practitioner is subjected, year in, year out, to the steady bombardment of the unscrupulous manufacturer, persuasive to the uncritical, on the principle that “what I tell you three times is true.” Against bad example and persistent asseveration, only precise scientific concepts and a critical
appreciation of the nature and limits of actual demonstration can protect the young physician.” (Flexner report, 1910, pp 64-65)

It is this very “appreciation of the nature and limits of actual demonstration” that is now being abandoned by the alternative medicine industry. despite the fact that real medicine was in its infancy at the time he w as writing, he was very perceptive about the problems. Perhaps Freedman should read the report.

David Katz seems to have spotted my piece in The Atlantic, and has responded at great length in the Huffington Post (quite appropriate, given the consistent support of HuffPo for nonsense medicine). HuffPo allows only short comments with no links so I’ll reply to him here.

I fear that Dr Katz doth protest a great deal too much. He seems to object to a comment that I made about him in The Atlantic.

“… [He] listed a lot of things he’d tried and which failed to work. His conclusion was not that they should be abandoned, but that we needed a ‘a more fluid concept of evidence.'”

You don’t have to take my word for it. You can take it from the words of Dr Katz.

"What do we do when the evidence we have learned, or if we care to be more provocative, with which we have been indoctrinated, does now fully meet the needs of our patients"

It seems odd to me to regard teaching about how you distinguish what;s true and what isn’t as "indoctrination", though I can understand that knowledge of that subject could well diminish the income of alternative practitioners. You went on to say

"Some years ago the CDC funded us with a million dollars to do what they referred to initially as a systematic review of the evidence base for complementary and alternative medicine,  Anybody who’s ever been involved in systematic reviews knows that’s a very silly thing. . . . Well we knew it was silly but a million dollars sounded real [mumbled] took the money and then we figurered we’d figure out what to do with it [smiles broadly]. That’s what we did ". . .

I do hope you told the CDC that you did not spend the million dollars for the sensible purpose for which it was awarded.

This infusion of calcium, magnesium and D vitamins and vitamin C ameliorates the symptoms of fibromyalgia.  . . .  We did typical placebo controlled randomized double-blind trial for several months . . . we saw an improvement in both our treatment and placebo groups . . .

You then describe how you tested yoga for asthma and homeopathy for attention deficit hyperactivity disorder, Neither of them worked either. Your reaction to this string of failures was just to say “we need a more fluid concept of evidence”

After telling an anecdote about one patient who got better after taking homeopathic treatment you said £I don’t care to get into a discussion of how, or even whether, homeopathy works”.  Why not?  It seems it doesn’t matter much to you whether the things you sell to patients work or not.

You then went on to describe quite accurately that anti-oxidants don’t work and neither do multivitamin supplements for prevention of cardiovascular problems,  And once again you fail to accept the evidence, even evidence you have found yourself. Your response was

“So here too is an invitation to think more fluidly about of evidence. Absence of evidence is not evidence of absence.” 

That last statement is the eternal cry of every quack.  It’s true, of course, but that does not mean that absence of evidence gives you a licence to invent the answer.  But inventing the answer is what you do, time after time, You seem quite incapable of saying the most important thing that anyone in your position should. I don’t know the answer.

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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.

Dear Member

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.

What next?

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

Follow-up

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.”

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