Mea culpa to the max. I completely forgot that today is my day to post on SBM, so I’m going to have to cheat a little. Here is a link to a recent article by yours truly that appeared on Virtual Mentor, an online ethics journal published by the AMA with major input from medical students. Note that I didn’t write the initial scenario; that was provided to me for my comments. The contents for the entire issue, titled “Complementary and Alternative Therapies—Medicine’s Response,” are here. Check out some of the other contributors (I was unaware of who they would be when I agreed to write my piece).

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Everything you know may be wrong. Well, not really, but reading the research of John Ioannidis does make you wonder. His work, concentrated on research about research, is a popular topic here at SBM.  And that’s because he’s focused on improving the way evidence is brought to bear on decision-making. His most famous papers get to the core of questioning how we know what we know (or what we assume) to be evidence.

His most recent paper takes a look at the literature on biomarkers. Written with colleague Orestis Panagiotou, Comparison of effect sizes associated with biomarkers reported in highly cited individual articles and in subsequent meta-analyses is sadly behind a paywall -  so I’ll try to summarize the highlights. Biomarkers are chemical markers or indicators that can be measured to verify normal biology, detect abnormal pathology, or measure the effect of some sort of treatment. Ever had blood drawn for lab tests? Then you’ve had biomarkers tested. Had your blood pressure checked? Another biomarker. The AACR-FDA-NCI cancer biomarkers consensus report provides a nice categorization of the different biomarkers currently in use:

• Diagnostic biomarkers
  • Early detection biomarkers
  • Disease classification
• Predictive biomarkers
  • Predict the response to a specific agent
  • Predict a particular adverse reaction
• Metabolism biomarkers
  • Biomarkers that guide drug doses
• Outcome biomarkers
  • Those that predict response
  • Those that predict progression
  • Those that forecast recurrence

Biomarkers are developed and implemented in medical practice in a process that parallels drug development. It starts with a hypothesis, then progressive research to validate the relationship between the measurement of a feature, characteristic, or parameter, and the specific outcome of interest. The assay process, for measuring the biomarker itself must also undergo its own validation, ensuring that measurements are accurate, precise, and consistent. Biomarkers are generally considered clinically valid and useful when there is an established testing system that gives meaningful, actionable results that can make a clinically meaningful difference the way we prevent or treat disease.

Some of the most common medical tests are biomarkers. Serum creatinine to estimate kidney function, levels of liver enzymes to evaluate liver function, and blood pressure to predict the risk of stroke.  The search for new biomarkers has exploded in the past several years with the growing understanding of the molecular nature of many diseases. Cancer therapies are among the most promising areas for biomarkers, with tests like HER2 (to predict response to trastuzumab), or the KRAS test (to predict response to EGFR inhibitors like cetuximab and panitumumab) guiding drug selection. It’s a very attractive target: Rationally devising drugs based on specific disease characteristics, and then using biomarkers to a priori to identify patients most likely to respond to treatment.

Despite their promise, the resources invested, and isolate winners, biomarker research has largely failed to live up to expectations for some time. Most recently, David Gorski discussed how the hype of personalized medicine hasn’t yet materialized into truly individualized treatments: not because we’re not trying, but because it’s really, really, hard work. I’ve also pointed out that the the direct-to-consumer genetic tests, some of which rely on biomarkers, is a field still not ready for prime time, where the marketing outpaces the science. The reality is that few new biomarker tests have been implemented in clinical practice in the past decades. For many medical conditions, we continue to rely on traditional methods for diagnosis. Yes the promise of biomarkers is tantalizing. Every major conference heralds some new biomarker that sounds predictive and promising.  So we have a hot scientific fields, lots of preliminary research, multiple targets and approaches, and significant financial interests at play. Sound familiar? It’s exactly the setting describe by Ioannidis on therapeutic studies, in his well-known paper, Why Most Published Research Findings Are False. And based on this latest paper, the biomarker literature seems to share characteristics with the literature on medical interventions, which Ioannidis studied in another well-known paper, Contradicted and Initially Stronger Effects in Highly Cited Clinical Research.

This newest paper, which was published earlier this month, sought to evaluate if highly cited studies of biomarkers were accurate, when compared to subsequent  meta-analyses of the same data. To qualify, each study had to have been cited over 400 times, and each study had to have a matching subsequent meta-analysis of the same biomarker relationship conducted as follow-up. To reduce the field from over 100,000 studies down to something manageable, results were restricted to 24 high impact journals with the most biomarker research.  Thirty-five base papers, published between 1991 and 2006 were ultimately identified. These were well-known papers – some have been cited over 1000 times. For each paired comparison, the largest individual study in each meta-analysis was also identified, and compared to the original highly cited trial. Biomarkers identified included genetic risk factors, blood biomarkers, and infectious agents. Outcomes were mainly cancer or cardiovascular-disease related.  Most of the original relationships identified were statistically significant, though four were not.

So did the original association hold up? Usually, no.  Of that sample of 35, subsequent analysis failed to substantiate as strong a link 83% of the time. And 30 of the 35 reported a stronger association than observed in the largest single study of the same biomarker. When the largest studies of these biomarkers were examined, just 15 of the 35 original relationships were still significantly significant, and only half of these 15 seemed to remain clinically meaningful. For example, homocysteine use to be kind of a big deal, after it was observed that a strong correlation existed between levels of this biomarker and cardiovascular disease, in a small study. The most well-know study has been cited in the literature 1451  times,  and reported an whopping odds ratio of 23.9.  Subsequent analyses of homocysteine failed to show such a strong association. Nine years after the initial trial, a meta-analysis of 33 trials with more than 16,000 patients calculated an odds ratio of 1.58. Yet this finding has been infrequently cited in the literature: only 37 citations to date.

The authors identify a number of reasons why these findings may be observed. Many of the widely cited  studies were preliminary and had small sample sizes. Publication interest could have led to selective reporting from looking for significant findings. The preliminary studies preceded the meta-analysis often by several years, giving ample time for citations to accrue (though this was not always the case, and in some cases, the highly cited studies followed larger studies.) Limitations identified included the biomarker selection process which included several arbitrary selection steps, including the citation threshold, and the requirement for a paired meta-analysis. The authors warn readers to be cautions when authors cite single studies and not meta-analyses, and conclude with the following warning:

While we acknowledge these caveats, our study documents that results in highly cited biomarker studies often significantly overestimate the findings seen from meta-analyses. Evidence from multiple studies, in particular large investigations, is necessary to appreciate the discriminating ability of these emerging risk factors. Rapid clinical adoption in the absence of such evidence may lead to wasted resources.

The editorial that accompanied the article (also paywalled) echos the cautions and concerns in the paper:

It would be premature to doubt all scientific efforts at marker discovery and unwise to discount all future biomarker evaluation studies. However, the analysis presented by Ioannidis and Panagiotou should convince clinicians and researchers to be careful to match personal to hope with professional skepticism, to apply critical appraisal of study design and close scrutiny of findings where indicated, and to be aware of the findings of well-conducted systematic reviews and meta-analyses when evaluating the evidence on biomarkers.

More of the (Fake) Decline Effect? No.

The so-called “Decline Effect” has been discussed at length here at SBM. The popular press seems to be quick to reach for unconventional explanations of the weakening of scientific findings under continued scrutiny. Steven Novella discussed a related case earlier this month, pointing out there’s no reason to appeal to quantum woo, when the decline effect is really just the scientific process at work: adding precision and reducing uncertainty through continued analysis.

Biomarker research parallels therapeutic research, with all the same potential biases. The earliest and often most highly cited results may ultimately turn out to be inaccurate and quite possibly significantly overstated.  Trial registration and full disclosure of all clinical trials will help us understand the true effect more quickly. But that alone won’t solve the problem if we continue to attach significant merit to preliminary data, particularly where there is only a single study. Waiting for confirmatory research is hard to do, given our propensity to act. But a conservative approach is probably the smartest one, given the pattern we’re seeing in the literature on biomarkers.

References

Ioannidis JP, & Panagiotou OA (2011). Comparison of effect sizes associated with biomarkers reported in highly cited individual articles and in subsequent meta-analyses. JAMA : the journal of the American Medical Association, 305 (21), 2200-10 PMID: 21632484

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There are a few “laws” of the blogosphere, one of them being that a response to a post that comes more than a few weeks later is generally useless or crazy.  But once in a while, someone takes the time to look at an old post and formulate a thoughtful response.

This is not one of those times.

Or maybe it is.  I’ll report (and editorialize), you decide.

Regarding a piece I first published in September of 2010, a reader writes:

Dear Dr. Gorski:[our managing editor]

I am writing regarding your comments on the following blog

Your disease, your fault

I am not a doctor but am pursuing an MA and hopefully a PhD in nutrition and public health. I am very familiar with Dr. Fuhrman and his work. I have heard many of Dr. Fuhrman’s lectures and if anything they are all based on concrete scientific research. I must express my disappointment about both the tone and factual content of the article written. I read extensively about nutrition, exercise and their health benefits. Much of the research done in this field has been conducted in small clinical trials or in the laboratory. There is a good reason for this. Only the government has the financial ability to pay the tens of millions of dollars needed to conduct large scale clinical trials in this area since a drug company would in all probability not have any financial gain from a clinical trial showing that individuals eating 10 servings of vegetables each day have a significant reduction in chronic disease. I do feel that all epidemiological as well as clinical work done points to the very clear fact that people die years before they need to due to the poor diets they have. It is also very clear that most physicians have very little knowledge about nutrition since it is generally a very minor part of their education. I agree with doctor Fuhrman that any debate should be both science based and held to the highest ethical standards. From what I see the article written as well as your comments do not meet these standards. I find that most disconcerting due to the fact that individuals put their lives in their hands when they consult with you as a physician.

In closing I would like your comment on the follwing statement that was made by Dr. William Castelli, who ran the Framingham Study for about 20 years. An interviewer asked him what percent of heart disease could be avoided through proper nutrition and exercise. His response was very brief. 100%!! Do you agree with one of foremost reaearcers of the 20th century or do you consider him to be a quack too.

I await your response.

Sincerely,

[Name redacted]

What is instructive here is the usual thoughtful but incorrect “reasoning” used by someone with just enough knowledge to think he understands the topic at hand well enough to rebut.  The rebuttal, however, makes use of the usual fallacies that are the fallback position for the ignorant and the mendacious (and I must point out that I think our Dear Correspondent is the former).

Since I wrote the piece, not Dr. Gorski, I take full responsibility for its content and defend my writing personally.  A bit of a fisking is in order to help us all better understand how to think about these questions properly.

I am not a doctor but am pursuing an MA and hopefully a PhD in nutrition and public health. I am very familiar with Dr. Fuhrman and his work. I have heard many of Dr. Fuhrman’s lectures and if anything they are all based on concrete scientific research. I must express my disappointment about both the tone and factual content of the article written.

The writer first tries to establish himself as an authority on nutrition, public health, and one Dr. Fuhrman (the putative antagonist of my piece) as a reliable source of that authority.  Even if we were to be convinced by his level of authority, it is irrelevant to his arguments.   Our Dear Correspondent could be a Nobel laureate in physics, but this is no guarantee of relevant expertise.

Then he begs the question: he asserts that Dr. Fuhrman’s works are “all based on concrete scientific research”.  This may or may not be true, but it does not refute the points made in my post, such as Furhman’s stated idea that all disease is preventable with just the right lifestyle and avoidance of medication.

He finishes his point with a non sequitur (although one that loyal reader Peter Moran might agree with), that somehow my tone renders my argument less valid.  If I were to point at the sky and shout, “It’s &%$# blue, you ass!” the statement would be no less true for its crudeness.

I read extensively about nutrition, exercise and their health benefits. Much of the research done in this field has been conducted in small clinical trials or in the laboratory. There is a good reason for this. Only the government has the financial ability to pay the tens of millions of dollars needed to conduct large scale clinical trials in this area since a drug company would in all probability not have any financial gain from a clinical trial showing that individuals eating 10 servings of vegetables each day have a significant reduction in chronic disease.

This is simply untrue.  There is an enormous body of research on nutrition and exercise physiology.  Just glancing at today’s issue of the American Journal of Cardiology, we see Impact of Body Mass Index, Physical Activity, and Other Clinical Factors on Cardiorespiratory Fitness (from the Cooper Center Longitudinal Study); from The Lancet, a summary of Salt and cardiovascular disease mortality. These fields (nutrition, exercise) are and have been active areas of high quality research, just not to the exclusion of all else.  It would be rather foolish to focus on only one set of tools to prevent a heart attack.  When lifestyle modification is inadequate, it is not a failure of the patient, the doctor, or science-based medicine, but a simple case of “stuff happens” and it’s time to crack open another tool box.

These facts render irrelevant his subsequent suspicion-filled assumptions about the economics of medicine.  The government funds a great deal of this research, but so do pharmaceutical and related industries.  There is always a profit to be made, whether by developing a new drug, or opening a Whole Foods with aisles full of magic (some of which is quite healthy and quite tasty).

I do feel that all epidemiological as well as clinical work done points to the very clear fact that people die years before they need to due to the poor diets they have. It is also very clear that most physicians have very little knowledge about nutrition since it is generally a very minor part of their education.

Not to wax Crislipian, but Duh! Our country is suffering from an epidemic of obesity, leading to early, preventable deaths.  That’s not particularly controversial.  It’s also not a mystery that many physicians receive an inadequate education in nutrition.  The fallacy here is that it is better to worship a false god than to seek true knowledge.  The cure to our ignorance is not to listen to some pseudo-expert who is completely wrong about disease prevention and treatment, but to improve our education of the public and our professionals.

I agree with doctor Fuhrman that any debate should be both science based and held to the highest ethical standards. From what I see the article written as well as your comments do not meet these standards. I find that most disconcerting due to the fact that individuals put their lives in their hands when they consult with you as a physician.

Well, that’s just ad hominem nonsense.  What counts is facts, not one writer’s opinion about tone and ethics.  This statement betrays a complete misunderstanding of medical ethics.  Our duty, as physicians, is first to our patients, then to the wider public.  We must treat the patient in front of us with the best science-based medicine has to offer, delivered with compassion.  We must educate the public to teach the difference between real doctors and carnival barkers (h/t POTUS).

In closing I would like your comment on the follwing statement that was made by Dr. William Castelli, who ran the Framingham Study for about 20 years. An interviewer asked him what percent of heart disease could be avoided through proper nutrition and exercise. His response was very brief. 100%!! Do you agree with one of foremost reaearcers of the 20th century or do you consider him to be a quack too.

I’m not so sure about that Castelli quote.  He has a history of some pretty bold pronouncements that don’t quite follow the evidence, but if you dig into his efforts a bit deeper, you can see that he clearly doesn’t believe the statement above:

Castelli concedes diet and exercise won’t help the 5 to 10 percent of people who’s heart disease is genetic. The genetic predisposition to heart disease is responsible for 85% of heart attacks suffered by people under 65. These people often have cholesterol levels of a whopping 300 or higher. Medication can save their lives, but the health care system, Castelli charges, doesn’t do a good enough job of finding these patients in time.

If our Dear Correspondent would like to learn more about how to think more clearly about medicine and science, this blog has been live for a few years now and offers a treasure trove for those interested in banishing ignorance, or at least learning to tell fact from its opposite.

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It has just been announced, in the July/August issue of Skeptical Inquirer magazine, that our own Steven Novella has been awarded the 2010 Robert P. Balles Annual Prize in Critical Thinking. It will be formally presented at the CSIcon conference in New Orleans on October 28, 2011. The Prize is a $1500 award given to the author of the published work or body of work that best exemplifies healthy skepticism, logical analysis, or empirical science. The Committee for Skeptical Inquiry (CSI) selects the publication that, in its judgment, has the greatest potential to create positive reader awareness of currently important scientific concerns. Previous awards starting in 2005 were for individual publications. In Dr. Novella’s case, the award was for his entire body of work. In the letter informing him of his selection, CSI Executive Director Barry Karr said,

…you are being honored for your tremendous body of work including The Skeptic’s Guide to the Universe, Science-Based Medicine, Neurologica, your SKEPTICAL INQUIRER column “The Science of Medicine,” as well as your tireless travel and lecture schedule on behalf of skepticism. You may well be the hardest worker in all of skepticism today. And to me, the truly amazing thing is you do all of this on a volunteer basis.

He is also the president and co-founder of the New England Skeptical Society, a fellow of CSI, a founding fellow of the Institute for Science in Medicine, a medical advisor to Quackwatch, a contributor to other blogs, has produced a course for The Teaching Company on “Medical Myths, Lies, and Half-Truths,” and is Senior Fellow and Director of the James Randi Educational Foundation’s (JREF) new Science-Based Medicine project. And I have undoubtedly omitted several of his other accomplishments.

It is hard to believe he hasn’t cloned himself, since all of these achievements are in addition to his demanding day job as a clinical neurologist, assistant professor, and director of general neurology at Yale University School of Medicine.

Congratulations, Steve! The award couldn’t have gone to a better candidate. I want to add my personal thanks for all you do and say how proud I am to be associated with you. You da man!

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Acupuncture has been in the news recently. A former President of South Korea had to undergo major surgery to remove an acupuncture needle that had somehow lodged in his lung.  A recent study in Pain compiled a list of 95 published reports of serious complications of acupuncture including 5 deaths. Meanwhile, acupuncturists continue to insist that their procedures are “safe.”

Edzard Ernst et al.’s article “Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews“ was published in the journal Pain in April 2011. It had two parts: (1) it was a systematic review of 57 systematic reviews showing that there was “little truly convincing evidence that acupuncture is effective in reducing pain,” and (2) it tabulated published reports of 5 deaths and 90 other serious complications of acupuncture treatments. I wrote an accompanying commentary, “Acupuncture’s claims punctured: Not proven effective for pain, not harmless.”

William Morris chastised me for not declaring a conflict of interest (!?) in my commentary. Now, in Acupuncture Today, he has criticized the Ernst et al. study itself.

Morris’ first criticism is that the study

did not examine iatrogenic deaths due to conventional drugs, chemotherapy, radiotherapy and surgery. It was more focused on the safety and efficacy of acupuncture.

I laughed out loud when I read this. It was focused on the safety and efficacy of acupuncture because it was a study about the safety and efficacy of acupuncture. Duh!  A study of acupuncture for pain is not the appropriate place to examine iatrogenic deaths from four conventional treatment methods that are used for every disease from pneumonia to cancer. We need to know about acupuncture’s efficacy and safety (for pain) before we can even consider making any meaningful comparisons with other treatments (for pain). He says “it would be interesting to see results an [sic] in-depth ‘review of reviews’ on the safety and efficacy of conventional medicine and surgery.” Sure it would, but this is hardly the place.  He tries to forestall protests by insisting this is not a tu quoque argument; but it sure sounds like it, or like something worse.

Comparing iatrogenic deaths from different treatments would be a valid subject for a different article. But why does he single out conventional medicine instead of including deaths from all forms of alternative medicine? What about the risk of stroke from neck manipulation? Neck manipulation would be a particularly pertinent comparison to acupuncture because it is used by many chiropractors to treat pain as an alternative to both conventional medicine and acupuncture. And why single out deaths instead of looking at all serious adverse events? Most importantly, why not look at risks in the context of proven benefits?

Curiously, Morris does not address the results of the systematic review of acupuncture’s efficacy or attempt to counter its conclusions in any way. He only briefly criticizes its methodology, and then he focuses on the reports of adverse effects.

The Systematic Review of Systematic Reviews

He criticizes Ernst et al. for lack of detail in describing how they quantified the quality of the studies they included in their analysis. But they supplied a footnote to an article describing their method, indicating that they followed Oxman and Guyatt’s validated checklist. Does Morris think they should have reproduced the entire checklist and evidence for its validation in the text of their article? I can’t fault them for using a footnote to save space.

“For data on efficacy, it doesn’t provide information about how the studies were controlled.” He wants to know whether it was “acupuncture alone, skin penetrating, non-penetrating or adjacent to the point location.” This only highlights the imprecision of acupuncturists’ own definitions of what qualifies as acupuncture and what constitutes appropriate controls. In my commentary I pointed out:

there are various schools of acupuncture with different acupoints, and studies of acupuncture have included “electroacupuncture” (with or without needles), ear acupuncture, cupping, moxibustion, and other loosely related procedures.

If he had any evidence that his preferred version of acupuncture was more effective or safer than other versions, or that one type of control is more appropriate than another, he could have presented it. He expresses doubts rather than offering data.

Safety

Morris criticizes Ernst et al. for including case reports where causality was uncertain, but each case report was listed individually and its causality categorized as certain or probable. The deaths were categorized as “certain” causality. Even if you eliminate the uncertain ones, the data show that acupuncture cannot be characterized as risk-free.

Bizarrely, he criticizes Ernst et al. for not including other complications such as fainting, vomiting, or bruising that are more common adverse effects. These are not “serious” risks, which is why they were not included in a study of “serious risks.” In essence, Morris seems to be arguing that acupuncture is even less safe than Ernst et al. depicted.

He says “Ernst and his colleagues do not reference previous studies showing acupuncture as safe,” citing a 2003 article by Lao and Berman published in an alternative medicine journal. That article’s conclusion included the authors’ opinion (a value judgment) that acupuncture is “a generally safe procedure”; but its text identified 202 adverse events, over twice as many as the Ernst et al. article. It included minor events like fainting and nausea, while the Ernst study was limited to serious events. I don’t have access to the full study. I wonder if it is exempt from the same criticisms: did its authors describe how they quantified the quality of the reports they included, did they assess the certainty of causation, and did they follow a validated checklist like Ernst et al. did?

Morris quotes a researcher who says “acupuncture is seen as an extremely safe therapeutic system whose complications are very rare and are easily avoided or rectified.”  This is not at all in conflict with the findings of the Pain study. Ernst et al. found a number of complications that was quite small in relation to the large number of acupuncture treatments, and they called for better training of acupuncturists to minimize the chance of complications. The real point is that there is no reason to accept any degree of risk, no matter how little, if there is no benefit to the treatment. Safety by itself is no recommendation: homeopathy is probably the safest treatment going.

Conflict of Interest

Morris criticized me for not declaring a conflict of interest in my commentary.  I have no conflict of interest: it makes no difference to me whether acupuncture works or not; I would follow the evidence wherever it led and write about it.  He, on the other hand, has a clear interest in defending his occupation, and I don’t see any declaration of his conflict of interest in his Acupuncture Today article. The Ernst et al. study is solid: it shows that there is little evidence that acupuncture is truly effective in reducing pain. Taken as a whole, a rigorous evaluation of the published evidence leads to the conclusion that acupuncture is no more effective than placebo, and it is not risk free.  Morris doesn’t want to accept this. He is biased in favor of acupuncture and is doing whatever he can to limit the damage from the Pain study. He can’t do much: his efforts are unconvincing and rather sad.

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Some of my fellow Science-Based Medicine (SBM) bloggers and I have been wondering lately what’s up with The Atlantic. It used to be one of my favorite magazines, so much so that I subscribed to it for roughly 25 years (and before that I used to read my mother’s copy). In general I enjoyed its mix of politics, culture, science, and other topics. Unfortunately, my opinion changed back in the fall of 2009, when, on the rising crest of the H1N1 pandemic, The Atlantic published what can only be described as an terrible bit of journalism lionizing the “brave maverick doctor” Tom Jefferson of the Cochrane Collaboration. The article, written by Shannon Brownlee and Jeanne Lenzer, argued, in essence, that vaccinating against H1N1 at the time was a horrendous waste of time and effort because the vaccine didn’t work. So bad was the cherry picking of data and framing of the issue as a narrative that consisted primarily of the classic lazy journalistic device of a “lone maverick” against the entire medical establishment that it earned the lovely sarcasm of our very own Mark Crislip, who wrote a complete annotated rebuttal, while I referred to the methodology presented in the article as “methodolatry.” Even public health epidemiologist Revere (who is, alas, no longer blogging but in his day provided a very balanced, science-based perspective on vaccination for influenza, complete with its shortcomings) was most definitely not pleased.

I let my subscription to The Atlantic lapse and have not to this day renewed it.

Be that as it may, last year The Atlantic published an article that wasn’t nearly as bad as the H1N1 piece but was nonetheless pretty darned annoying to us at SBM. Entitled Lies, Damned Lies, and Medical Science, by David Freedman, it was an article lionizing John Ioannidis (whom I, too, greatly admire) while largely missing the point of his work, turning it into an argument for why we shouldn’t believe most medical science. Now, Freedman’s back again, this time with a much, much, much worse story in The Atlantic in the July/August 2011 issue under the heading “Ideas” and entitled The Triumph of New Age Medicine, complete with a picture of a doctor in a lab coat in the lotus position. It appears to be the logical follow up to Freedman’s article about Ioannidis in that Freedman apparently seems to think that, if we can’t trust medical science, then there’s no reason why we shouldn’t embrace medical pseudoscience.

Basically, the whole idea behind the article appears to be that, even if most of alternative medicine is quackery (which it is, by the way, as we’ve documented ad nauseam on this very blog), it’s making patients better because of placebo effects and because its practitioners take the time to talk to patients and doctors do not. In other words, Freedman’s thesis appears to be a massive “What’s the harm?” argument coupled with a false dichotomy; that is, if real doctors don’t have the time to listen to patients and provide the human touch, then let’s let the quacks do it. Tacked on to that bad idea is a massive argumentum ad populum portraying alternative medicine as the wave of the future, in contrast to what Freedman calls the “failure” of conventional medicine.

Let’s dig in, shall we? I’ll start with the article itself, after which I’ll examine a few of the responses. I’ll also note that our very own Steve Novella, who was interviewed for Freedman’s article, has written a response to Freedman’s article that is very much worth reading as well.

CHOOSE: HARRIED UNCARING DOCTORS OR QUACKS

You know an article about medicine going to be bad, at least on the science, when it starts out with a sympathetic profile of Brian Berman after an introduction that reads:

Medicine has long decried acupuncture, homeopathy, and the like as dangerous nonsense that preys on the gullible. Again and again, carefully controlled studies have shown alternative medicine to work no better than a placebo. But now many doctors admit that alternative medicine often seems to do a better job of making patients well, and at a much lower cost, than mainstream care—and they’re trying to learn from it.

One of these “many doctors” is, apparently, Dr. Brian Berman. One also notes that nowhere in Freedman’s article is a shred of compelling evidence is presented to support the assertion that alternative medicine can do a better job of making patients well at a much lower cost. It’s all assertions and speculations by “experts” in the field. In any case, regular readers might remember Dr. Berman, who has been featured on this very blog for his advocacy of quackademic medicine, most recently after he managed to get a credulous article about acupuncture into the New England Journal of Medicine (discussed by Mark Crislip and myself). Then, not unlike the vast majority of the evidence that CAM practitioners prefer over basic science and clinical trials, Freedman segues right into an anecdote about a man named Frank Corasaniti, a 60-year-old retired firefighter who had injured his back falling down a steel staircase at a firehouse some 20 years earlier and had subsequently injured both shoulders and his neck in the line of duty. Corasaniti was suffering from chronic pain due to his old injuries and at the urging of his wife tried acupuncture at Dr. Berman’s clinic under the direction of an acupuncturist named Lixing Lao. The consultation is described thusly:

Their first visit had lasted well over an hour, Corasaniti says, time mostly spent discussing every aspect of his injuries and what seemed to ease or exacerbate them, and also other aspects of his health–he had been gaining weight, he was constipated, he was developing urinary problems. They talked at length about his diet, his physical activity, his responsibilities and how they weighed on him. Lao focused in on stress–what was causing it in Corasaniti’s life, and how did it aggravate the pain?–and they discussed the importance of finding ways to relax in everyday life.

All of which is nothing that a real doctor couldn’t or wouldn’t do and completely unobjectionable. It’s what comes next that is the problem, as Lao tells Mr. Corasiniti about how acupuncture “works”:

Then Lao had explained how acupuncture would open blocked “energy pathways” in his body, allowing a more normal flow of energy that would lessen his pain and help restore general health. While soothing music played, Lao placed needles in and around the areas where Corasaniti felt pain, and also in his hands and legs, explaining that the energy pathways affecting him ran throughout his body.

Mr. Corasaniti feels better now; therefore acupuncture works.

I wonder how closely Lao is supervised by Dr. Berman or what the formal arrangement is, because, quite frankly, from the description I see here it sure sounds as though Lao is practicing medicine without a license. What are his qualifications in nutrition? Is he a dietician? What are his qualifications as a counselor or psychologist? In the article, Lao is described as a physiologist with Dr. Berman’s center, which to me sounds as though he has no legitimate qualifications whatsoever to be discussing diet and counseling Corasaniti how to deal with his chronic injuries. Yet there he is, practicing what sound to me like dietetics, counseling, and even medicine without a license at a major academic medical center. That’s leaving aside how, by Freedman’s own report, “practitioners” like Lao, with the approval of doctors like Berman, telling patients that there is a magical life force whose flow acupuncturists can rearrange to therapeutic effect by sticking little sharp objects into their bodies. Indeed, if there’s one thing I’ve found about alt-med, it’s that the supposedly “sensible,” science-based advice about diet and exercise that it’s co-opted as somehow “alternative” and pointed to as being better than what physicians offer often turns out not to be so sensible or science-based when you look at it more closely. Fad diets, supplements, various “detox” diets are all par for the course. We’ve pointed out numerous examples right here on this very blog of pure pseudoscience in medical schools and academic medical centers—even, I hate to admit it, at my medical alma mater.

Freedman then delves into what he apparently views as the failure of scientific medicine, beginning by proclaiming that “on balance, the medical community seems to be growing more open to alternative medicine’s possibilities, not less.” Unfortunately, I can’t actually argue with this assessment; thanks to the infiltration of unscientific CAM into former bastions of SBM like the University of Maryland, quackademic medicine is indeed coming to the fore, but Freedman seems to be arguing that this is a good thing rather than a bad thing because to him scientific medicine has “failed.” This leaves Freedman making this argument as to why quackademic medicine is so popular:

That’s in large part because mainstream medicine itself is failing. “Modern medicine was formed around successes in fighting infectious disease,” says Elizabeth Blackburn, a biologist at the University of California at San Francisco and a Nobel laureate. “Infectious agents were the big sources of disease and mortality, up until the last century. We could find out what the agent was in a sick patient and attack the agent medically.” To a large degree, the medical infrastructure we have today was designed with infectious agents in mind. Physician training and practices, hospitals, the pharmaceutical industry, and health insurance all were built around the model of running tests on sick patients to determine which drug or surgical procedure would best deal with some discrete offending agent. The system works very well for that original purpose, against even the most challenging of these agents–as the taming of the AIDS virus attests.

But medicine’s triumph over infectious disease brought to the fore the so-called chronic, complex diseases–heart disease, cancer, diabetes, Alzheimer’s, and other illnesses without a clear causal agent. Now that we live longer, these typically late-developing diseases have become by far our biggest killers. Heart disease, prostate cancer, breast cancer, diabetes, obesity, and other chronic diseases now account for three-quarters of our health-care spending. “We face an entirely different set of big medical challenges today,” says Blackburn. “But we haven’t rethought the way we fight illness.” That is, the medical establishment still waits for us to develop some sign of one of these illnesses, then seeks to treat us with drugs and surgery.

This is pure piffle. Preventative medicine is part and parcel of primary care, and by definition screening programs for disease (such as mammography) are anything but “waiting for us to develop some sign of one of these illnesses). Similarly, primary prevention (treating hypertension, for instance) is all about preventing serious diseases, such as heart disease or stroke. Moreover, because of our success against infectious diseases, people are now living long enough that chronic degenerative diseases, such as heart disease and cancer, have come to the fore, and these diseases are much more difficult to deal with than infectious diseases that can be cured with the right antibiotic. Basically, when you boil it all down, Blackburn’s assessment is nothing more than the same old complaint against “reductionistic Western medicine” that CAM supporters trot out again and again. The only difference is that it’s tarted up with a “just so” story about how modern medicine supposedly evolved that bears little resemblance to reality and is not questioned. It’s also presented as though physicians haven’t advocated healthy lifestyle interventions for many decades now. In Freedman’s narrative, cribbed from Blackburn, and then placed on steroids by Freedman, in come CAM and “integrative medicine” to deal with chronic disease.

Next comes a favorite CAM trope about how the U.S. spends more on health care than any other nation and has worse outcomes:

All of these shortcomings add up to a grim reality: as a prominent 2000 study showed, America spends vastly more on health as a percentage of gross domestic product than every other country–40 percent more than France, the fourth-biggest payer. Yet while France was ranked No. 1 in health-care effectiveness and other major measures, the United States ranked 37th, near the bottom of all industrialized countries.

This observation, even though true, is utterly irrelevant to the central thesis of Freedman’s article, namely that CAM can somehow improve health care in the U.S. The reason is that France, just as much as the U.S., uses SBM, not CAM. Nor does France, as far as I have been able to tell, “integrate” quackery with its “conventional” medicine any more than the U.S. does. Yet Freedman conflates two unrelated issues in order to suggest that CAM can show us the way out of the perceived “failure” of SBM because of its emphasis on “prevention” and “wellness” and the allegedly closer, more caring relationship between provider and patient, without providing anything other than anecdotes and argumentum ad populum to demonstrate that this might be so.

The one part of the article that comes closest to making sense is when Steven Novella is quoted as saying, “Alternative practitioners have a big advantage. They can lie to patients. I can’t.” This ethical problem appears not to bother Freedman at all. So enamored is he of placebo effects due to CAM that he proceeds to use and abuse them in the same way that Mike Adams did when he was seemingly amazed enough to discover that there are placebo effects in medicine that he tried to argue in a massive tu quoque argument that “Western medicine” is every bit as much a placebo as alt-med. Freedman’s argument, stripped to its essence, is no different than Mike Adams’. Freedman even pulls out an argument that I like to call, “Your Western science can’t study my woo because it’s ‘individualized,’” an argument much favored by woo-meisters:

Randomized controlled trials, the medical world’s gold standard for assessing the efficacy of treatments, cannot really test for this effect. Such studies are perfect for testing pills and other physically administered treatments that either have a direct physical benefit or don’t. (In its simplest form, a controlled study randomly assigns patients to receive either a drug or the equivalent of a sugar pill. If the real thing doesn’t bring on more improvement than the placebo does, the drug is a washout.) But what is it that ought to be tested in a study of alternative medicine? To date, the focus has mostly been on testing the physical remedies by themselves–divorced from any other portion of a typical alternative-care visit–with studies clearly showing that the exact emplacement of needles or the undetectable presence of special ingredients in homeopathic water isn’t really having any significant physical effect on the patient.

But what’s the sham treatment for being a caring practitioner, focused on getting a patient to adopt healthier attitudes and behaviors? You can get every practitioner in each of the study groups to try to interact in exactly the same way with every patient and to say the exact same things–but that wouldn’t come close to replicating what actually goes on in alternative medicine, where one of the main points is to customize the experience to each patient and create unique bonds.

This particular argument is, of course, utter nonsense, as has been pointed out time and time again. If Freedman couldn’t find at least a few studies examining the question of how much of a treatment is due to nonspecific or placebo effects and how much is due to actual interventions themselves, he just wasn’t looking very hard. The bottom line is that Freedman’s article is built on a false dichotomy. Basically, he seems to be arguing that, because conventional doctors are constrained by our current visit-based system of reimbursement from spending a lot of time with patients to get to know them better, empathize with them more, and deal with psychosocial issues, we should cede that aspect of patient care to quacks, letting them step into the breach, so to speak. No, that’s not a straw man position; that’s really what one can reasonably conclude to be Freedman’s argument. He just wouldn’t call it “quackery.” I would in many (but not all) cases. The reason I would is because what comes in with all the caring attention to patients is often pure pseudoscience based on prescientific vitalism. That’s what homeopathy, acupuncture, reiki, and various forms of “energy healing” popular today are. There has to be another way to bring back the “personal touch” and more attentiveness to patients besides telling them that if they want that personal attentiveness they have to go to a quack, which is what Freedman, for all his denials, does, whether he realizes it or not, whether he’ll admit it or not.

THE ATLANTIC SHOWS ITS HAND

As it sometimes does for controversial issues, The Atlantic is hosting an online “debate” about Mr. Freedman’s article and alternative medicine in general, in this case entitled Fix or Fraud? You can tell from the very beginning exactly which side of the issue The Atlantic comes down on by its choice of debaters. (Hint: It’s not “fraud.”) The lineup is stacked with “heavy hitters” in the alt-med movement, all arrayed against Steve Salzberg, who appears to have agreed to take on the role of the token skeptic as he correctly entitled his rebuttal A “triumph” of hype over reality. Besides the author of The Atlantic‘s paean to alt-med, arrayed against Salzberg are:

• Josephine Briggs, MD, PhD, Director, National Center of Complementary and Alternative Medicine (NCCAM), and Jack Killen, MD, Deputy Director, NCCAM: Don’t Dismiss These Treatments as Placebos
• Andrew Weil, MD, Founder, Arizona Center for Integrative Medicine: Changing Times Call for Smarter Doctors

The rest of the “panelists,” who have not yet contributed responses as of this writing, include Dean Ornish, MD, “pioneering researcher of preventative medicine”; Mimi Guarneri, MD, Founder of the Scripps Center for Integrative Medicine (who also appeared as the pro-CAM physician paired with Dr. Novella on The Dr. Oz Show nearly two months ago); Vasant Lad, director of the Ayurvedic Institute; and Reid Blackwelder, MD, Board Member of the American Academy of Family Physicians who has written credulously about CAM. A more blatantly stacked panel it’s hard to imagine, short of adding Deepak Chopra and Dr. Oz himself! It must have been a painful decision for Steve Salzberg to agree to be the token skeptic; I don’t know what I would have done in his place. Or maybe he didn’t know when he agreed to do it.

Given the wealth and length of the text produced by this team of CAM apologists, I clearly have to do something that doesn’t come natural to me and point out only a few of the most blatantly wrong and misguided arguments, nearly all of which, it should be noted, Mr. Freedman supports when he pipes in. I can also point out that Steve Novella took the time to rebut some of Mr. Freedman’s responses to complaints made by Steve and others, so that I don’t have to. It is interesting, however, to note that in these comments, Mr. Freedman “takes the gloves off,” so to speak and lets his true pique at being criticized show, even as he tries to paint his critics’ responses as emotional, “hot and bothered” knee jerk insults rather than considered responses to his plethora of logical fallacies. On his own blog, he goes on and on about how our responses are so “angry” and elsewhere even goes so far as to accuse his critics of “scienceology,” which he defines as a “quasi-religious faith in a set of closely held beliefs that are dressed up in the trappings of science and kept immune to any counter-evidence or -opinion.” As Steve pointed out, Freedman got the word wrong and didn’t need to make one up. A word already exists to describe the concept Freedman is driving at, and that word is “scientism.” Scientism, by the way, is a favorite charge of advocates of pseudoscience, be it alternative medicine, evolution denialism (i.e., creationism), or whatever. In any case, if you want a taste of how Freedman responds to criticism, here’s an excerpt from his own blog:

Those two basic arguments underlie Gorski’s particularly rabid rant, too. But if you read it, you’ll quickly find yourself buried in a detailed, apparently point-by-point refutation of virtually everything I say in my article. He goes through the article paragraph by paragraph, sentence by sentence, finding in each the logical flaw, the fallacy, the error of argument. Do I compare A and B? Then I’m a fool because A and B are different! Do I contrast C and D? Then I’m a fool, because it’s a false dichotomy! Do I assert a point about science? What do I know about science, I’m a journalist, and therefore a fool! Do I quote a Nobel Laureate? Then I’m a fool, because I’m arguing from authority! Do I point out a problem with mainstream medicine? Then, fool that I am, I’m setting up a straw man! Do I cite a study? Then I’m a fool, because that study was trash, or I’ve misinterpreted it, or it doesn’t apply here! Do I say that randomized studies, the gold standard of medical science, can’t really settle the question of whether alternative medicine might ultimately do a better job in some ways? Then I’m a fool, because any question can be settled with randomized trials, and in fact the studies have been done!

Except that I’ve never called Freedman a fool in any of my posts, either here or on my other blog, leaving me to marvel at his thin skin. Seriously. Go back and read if you don’t believe me. I’ve simply argued that he drew the wrong conclusions from his research and that he, as every writer must do, framed his presentation to support those conclusions. Apparently he can’t distinguish between criticism of his sloppy arguments and criticism of himself, although I do agree that Mr. Freedman did commit every sin of argumentation that he lists in the paragraph above, even as he frames my earlier criticism of his arguments as now a “rabid rant.” Personally, I’m more than happy for readers to compare Mr. Freedman’s own rant with my actually rather mild “rant” and decide whose is the more “rabid.” I also note that Freedman’s argument boils down to assuring us that, yes, he has done the research and that there is “no tearing apart Gorski could produce that I couldn’t in turn rip to shreds.” Trust him on that one, except that, for the umpteenth time, Mr. Freedman fails to produce any scientific evidence or examples to refute a single thing I’ve written and falls back on arguing from authority and straw men, such as claiming that I routinely assert that “alternative medicine is a purely evil and harmful thing that must be crushed.”

But enough of Freedman’s pique at having his work criticized. From now on, I’ll focus primarily on the framing of the pro-alternative medicine responses in The Atlantic “debate.” Freedman’s central thesis was that, even though he openly admits that alt-med is, by and large, placebo medicine and that many of the concepts behind its major modalities (for instance, acupuncture, homeopathy, and reiki) are pseudoscientific nonsense, alt-med still does a “better job of making patients well, and at a much lower cost.” Let’s start with Dr. Briggs and Dr. Killen, the heart of whose argument appears to be similar to Freedman’s. After pointing out that the most common problem for which people turn to CAM is chronic pain and that pharmacotherapy of chronic pain has problems, she argues:

Evidence is growing, based on carefully controlled studies, that certain non-pharmacological complementary interventions may be useful adjuncts to conventional care. For example, the pain of osteoarthritis can be lessened by acupuncture; tai chi may be helpful in reducing the pain of fibromyalgia; and massage and manipulative therapies may contribute to the relief of chronic back pain and related functional impairments. Furthermore, evidence from basic research points to ways in which such interventions use the body’s own pathways known to be involved in response to pain.

Let’s look at the latter two first. I discussed the tai chi/fibromyalgia paper when it came out. It’s nothing more than more of the classic “bait and switch,” because there is nothing unique to tai chi that can be invoked as the cause of better subjective outcomes. Basically, the study should have concluded that gentle exercise is better than, in essence, doing nothing other than talking and a bit of stretching for fibromyalgia. As I put it at the time, the “alternative” frame succeeded. The best you can say about this paper is that it showed that tai chi-style exercise for a longer period of time is better than stretching exercise and talking for a shorter period of time every day using an unblinded study. Similarly, no one argues that massage doesn’t make patients feel better or that manipulative therapies can’t help back pain. Indeed, physical therapists do manipulative therapy all the time. The difference is that they use more science-based interventions. There’s a reason I sometimes refer to chiropractors as “physical therapists with delusions of grandeur.” Physical therapists rely on the physical and don’t claim to be able to help anything not related to the musculoskeletal system. In contrast, many chiropractors infuse their craft with all sorts of woo-ful references to the “vital force” and flow of nerve impulses that have far more to do with a vitalistic, prescientific understanding of disease than with science. As for the acupuncture study, it’s certainly possible to find “positive” acupuncture studies; random noise in clinical trial results, bias, and publication bias will guarantee that. When you look at the totality of evidence for acupuncture, it is resoundingly negative for anything other than placebo or nonspecific effects.

Here’s the NCCAM leadership falls for the CAM frame and false dichotomy promoted by Freedman:

As Freedman also notes, research suggests that non-specific effects often make important contributions to the benefits patients may experience. For example, acupuncture involves a complicated interaction – including the stimulus of needles and their placement, expectancy, touch, a soothing environment, and a reassuring, supportive practitioner – that science has yet to disentangle.

Should we dismiss any benefits as mere placebo effects? Or should we explore the possibility, increasingly suggested by the science, that some complementary interventions provide powerful tools for studying the contributions of attention, touch, time, and reassurance, which are now in short supply in our health care system?

How many times does it need to be repeated that just because science doesn’t know everything doesn’t mean that you can fill in the gaps with “whatever fairy tale most appeals to you” or that it’s not necessary to study pseudoscientific, vitalistic, nonsensical health care systems based on a prescientific understanding of disease in order to determine the relative contributions of provider-patient interactions, nonspecific effects, and placebo effects versus actual benefit from medical treatments themselves? Apparently ad nauseam, because this canard keeps popping up again and again and again, Whac-A-Mole-style.

Moving on to Dr. Weil’s response, I can see from it just why he is the master of obfuscatory language in the service of CAM, as I discussed last month when I looked at his attack on evidence- and science-based medicine. Just look at the title which I’ll paraphrase: The times, they are a-changin’ and we need “smarter” doctors. Note the not-so-subtle implication that, by contrast, CAM opponents must be stupid Luddites who refuse to change with the times, a favorite framing device of CAM promoters. Then, to emphasize his mastery of language, Weil states:

Using synthetic drugs and surgery to treat health conditions was known just a few decades ago simply as “medicine.” Today, this system is increasingly being termed “conventional medicine,” and is the kind of medicine most Americans still encounter in hospitals and clinics. While often expensive and invasive, it is also extremely good for many things, such as medical and surgical emergencies. Some conventional medical approaches are scientifically validated, while others are not.

Any therapy typically excluded by conventional medicine, and that patients use instead of conventional medicine, is known by the catch-all term “alternative medicine.” Alternative therapies are generally perceived as being closer to nature, less expensive and less invasive than conventional therapies, although there are exceptions. Some alternative therapies are scientifically validated, some are not.

Note the dismissiveness towards “conventional” medicine, in particular the framing of its using only “synthetic” drugs and surgery. Never mind that many of the most commonly used drugs are every bit as much derived from natural products as anything touted by an herbalist. Sure, Dr. Weil says, SBM’s good for emergencies (I picture Dr. Weil looking down his nose as he says this, like a desert Santa Claus chastising a naughty child who won’t be getting anything for Christmas), but it’s “expensive and invasive.” Contrast this to the happy, “natural” CAM therapies that are “inexpensive” and “less invasive” than conventional therapies (except, apparently, when they’re not). And just like CAM, some of its approaches are scientifically validated and some are not! Got it? The two are equivalent! Except that Weil has constructed a false equivalency, given that the only alternative therapies that are “scientifically validated” are the ones that CAM has appropriated from SBM, such as diet and exercise, and Dr. Weil, not surprisingly, tries to use them as the proverbial Trojan Horse that I frequently reference:

Use of alternative medicine is but one component of integrative medicine. It attracts the most attention and the harshest criticism. But is nutrition counseling alternative? How about exercise recommendations? What about prescribing botanicals such as saw palmetto for benign prostatic hyperplasia or red rice yeast to lower cholesterol? There is as much or more hard science establishing the efficacy and safety of these therapies as there is behind drug interventions.

See what I mean? Notice how Dr. Weil blatantly co-opts science-based modalities, such as diet and exercise, as being somehow “alternative” when they are not and assiduously avoids any mention of the more hard core CAM modalities, such as “energy healing,” reiki, or homeopathy. Also, saw palmetto doesn’t work for prostatic hypertrophy, and the reason that red rice yeast appears to work to lower cholesterol is because it contains lovastatin, as the Mayo Clinic points out. Basically, as our very own Harriet Hall pointed out, using red rice yeast to lower cholesterol levels involves taking an uncontrolled and unregulated amount of an adulterated pharmaceutical drug. That makes it the height of chutzpah for Weil to claim that there is “as much or more hard science establishing the efficacy and safety of these therapies as there is behind drug interventions.” He can’t resist engaging in a bit of typical pharma-bashing, too.

In the end, Weil “frames” his version of “integrative medicine” not, as he should, as “integrating” quackery with science but rather as aiming to:

1. Restore the focus of medical teaching, research, and practice on health and healing;
2. Develop “whole person” medicine, in which the mental, emotional and spiritual dimensions of human beings are included in diagnosis and treatment, along with the physical body;
3. Take all aspects of diet and lifestyle into account in assessing health and the root causes of disease;
4. Protect and emphasize the practitioner/patient relationship as central to the healing process;
5. Emphasize disease prevention and health promotion.

These are all noble ideas, but none of them requires integrating pseudoscience- and belief-based medicine with SBM; yet that is the false dichotomy that Freedman and Weil promote in their articles.

WINNING THE FUTURE OF MEDICINE

Finishing his article, Freedman looks to the future, proclaiming that the next generation of physicians will determine whether alternative medicine takes hold. Not surprisingly, Dr. Weil finishes his article the same way, proclaiming integrative medicine to be “the future of medicine and healthcare.” Meanwhile, in his responses, Freedman simply doubles down on his original article, repeating how he’s making his arguments “with the explicit support of many prominent researchers and physicians” and blithely dismissing both Steve Salzberg’s devastating retort to him, as well as inconvenient criticisms that he considers too harsh as doing away “with all pretenses of objectivity, civility, or respect for evidence and reason.” One can’t help but note that nowhere has Freedman actually been able to refute a single one of the criticisms thus far leveled against him with anything resembling sound arguments or scientific data.

Unfortunately, Weil and Freedman are probably correct about pseudoscience being the future of a disturbingly large swath of medicine. There’s a reason why promoters of unscientific medicine such as the Bravewell Collaborative are focusing so heavily on medical education and setting up “integrative medicine” programs at academic medical centers and bolstering its consortium of CAM-friendly academic medical centers. They’re playing for the long term; there’s no doubt about that. Right now, they’re succeeding, too. The infrastructure is rapidly being built to subvert science in the bastions of academia and replace it with quackademic medicine. Freedman views this as a good (or at least neutral) thing.

We at SBM do not.

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