A “Double Standard”?

Last week I had planned to write a comprehensive critique of a recent comment by Larry Dossey. He had posted it on Val Jones’s betterhealth website in response to Dr. Val’s essay, “The Decade’s Top 5 Threats To Science In Medicine,” originally posted here on SBM. Much of what Dr. Val had identified as the top threats involved recent dalliances, by government, medical schools, and the media, with the collection of implausible and mostly nonsensical health claims that advocates have dubbed “CAM.” As uncontroversial as Dr. Val’s assertions ought to have been—similar to suggesting that closing one’s eyes and “using the force” would be a threat to safe driving (even if some might quibble over the top threats to science in medicine)—Dr. Dossey demurred by distraction:

Your article implies that conventional medicine is grounded in evidence-based research and that CAM is not. This is grossly overstated, and suggests that a double standard is being applied to these fields.

Dossey trotted out familiar arguments: “Much, if not most, of contemporary medical practice still lacks a scientific foundation”; “the Congressional Office of Technology Assessment (OTA) found that only an estimated 10 to 20% of the techniques that physicians use are empirically proven”; hospital care is “the third leading cause of death in the United States,” accounting for hundreds of thousands of deaths each year.

He concluded with an appeal to fairness, rationality, and collegiality:

Overwhelming evidence reveals that conventional medicine is, on the whole, woefully unscientific. It’s fashionable and easy to deny this, but the facts say otherwise. So, by all means, Dr. Val, be critical of CAM – but do not fall into a double standard. Let us ruthlessly apply science to ALL we do as physicians. Let us challenge ALL areas of medicine to a higher standard. On that, I’m pretty sure we can agree.

Keep up the good work.

Sincerely yours,
Larry Dossey, MD

I procrastinated with my own rebuttal, and in the meantime David Gorski responded to similar language found in an article by Dossey (and two other magical thinkers) titled “The Mythology of Science-Based Medicine,” published by the Huffington Post. I’ll not repeat Dr. Gorski’s able rebuttal in any detail, and I’ve already written about much of what this matter brings to mind. Examples are here, here, and here on the perils of conflating science-based medicine and Evidence-Based Medicine (EBM); here on the false dichotomy of modern medicine vs. “CAM”; here on a concise definition of “CAM”; here and here on the mischief spawned by demands to “ruthlessly apply science,” in the narrow, EBM sense of the word, to implausible health claims; here (point #7) and here regarding the tu quoque fallacy, the “10-20% empirically proven” claim, and the risks of modern health care; here (scroll down to “this week’s entry”) and here, regarding some of Dossey’s own opinions about science and the future of medicine.

For now I’ll elaborate on a few points. These pertain not only to Dr. Dossey but also to myths common to the advocacy of pseudomedicine, so I hope to provide some useful information.

The “10-20% of Medical Treatments are Empirically Proven” Myth

Several years ago our fellow blogger David Ramey and his co-author, the late Bob Imrie, debunked the ‘10-20%’ claim in an article with a hard-to-miss title, “The Evidence for Evidence-Based Medicine.” They showed not only that the percentages of evidence-based treatments are much higher for various medical specialties, but that the original ‘10-20%’ figure attributed to the OTA had been little more than an off-the-cuff quip, as its author had been trying to explain for more than 20 years.

Drs. Ramey and Imrie published their paper in Complementary Therapies in Medicine in 2000, and shortly thereafter it was reprinted in the Scientific Review of Alternative Medicine. It’s curious that Dr. Dossey, who at the time was Executive Editor of a related journal, Alternative Therapies in Health and Medicine, seems to have been unaware of such a provocative reference.

The “Third Leading Cause of Death” Myth

As Dr. Gorski noted, Dr. Harriet Hall provided an excellent rebuttal of this claim a couple of years ago. Her main point was this:

If the doctor-bashers want to play statistics, how about comparing death rates with modern scientific medicine to death rates with alternative medicine and death rates with no medicine at all. That might really be interesting!

I think they’ve got it backwards. The biggest cause of death is not medicine, but a failure to use medicine. The blame is shared by patients who don’t follow preventive guidelines, by doctors who don’t practice the best science-based medicine, and by all those who reject science-based medicine in favor of belief-based alternatives.

The most widely quoted source for the Deaths claim, also cited by Dossey, is the 2000 report from the Institute of Medicine (IOM) titled “To Err is Human: Building a Safer Health System.” The IOM report made headlines with these assertions:

Health care is not as safe as it should be. A substantial body of evidence points to medical errors as a leading cause of death and injury.

• Sizable numbers of Americans are harmed as a result of medical errors. Two studies of large samples of hospital admissions, one in New York using 1984 data and another in Colorado and Utah using 1992 data, found that the proportion of hospital admissions experiencing an adverse event, defined as injuries caused by medical management, were 2.9 and 3.7 percent,1 respectively. The proportion of adverse events attributable to errors (i.e., preventable adverse events) was 58 percent in New York, and 53 percent in Colorado and Utah.

• Preventable adverse events are a leading cause of death in the United States. When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of these two studies imply that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors. Even when using the lower estimate, deaths in hospitals due to preventable adverse events exceed the number attributable to the 8th-leading cause of death. Deaths due to preventable adverse events exceed the deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297) or AIDS (16,516).

Without, apparently, considering the years that the key data had been gathered, the IOM committee made this pronouncement:

Given current knowledge about the magnitude of the problem, the committee believes it would be irresponsible to expect anything less than a 50 percent reduction in errors over five years.

The numbers cited by the IOM report were immediately challenged, most importantly because the studies from which they’d been gleaned had lacked control groups. Thus the questions posed by Dr. Hall were raised: how many patients who died, subsequent to an apparent adverse event, would have died during a similar time frame without hospital care? How many would have died even with hospital care but without such an event? There is no way to know from the two studies cited by the IOM. Nevertheless, most of the patients in question were clearly in high-risk groups, so it is reasonable to imagine that many or even most of them might have died.

The two studies also suffered from a lack of inter-rater reliability and (I am not making this up) from not having defined “preventable adverse events.” Two good summaries of why the IOM’s estimates had been flawed were offered during subsequent rounds of responses to the controversy. First:

Dr. McDonald and colleagues provide an important critique of the IOM report on medical errors and of the Harvard Medical Practice Study (MPS) that is integral to it. McDonald et al correctly argue that the basis of estimating death rates due to medical adverse events was inappropriate because a high-severity group was chosen for analysis without a control group to provide context and because a causal relationship was not established between the existence of adverse events and subsequent death.

In fact, the headline number of 98,000 deaths annually due to medical error does not represent actual deaths but is conflated from a flawed analysis of fewer than 200 actual deaths in the index 1984 study. (The lower number of 44,000 deaths was derived in the same manner from a 1992 study of data from Colorado and Utah). The original MPS authors noted that a blinded analysis by a second team of their own reviewers failed to identify the same set of adverse events as the first team, but they did find the same incidence of adverse and negligent adverse events. Nonetheless, the authors declared their data reliable. This is roughly equivalent to saying it does not matter whether we incarcerate the innocent or the guilty as long as the overall number of convictions matches the crime rate. Even more remarkable, the MPS reviewers agreed only 10% of the time on the simple presence or absence of medical negligence. The study methods were sufficiently idiosyncratic that the authors themselves found no correlation whatsoever between their determinations of medical negligence and the outcome of malpractice verdicts.

It is interesting that the IOM report calls for a national goal of a 50% reduction in medical error. Although this is indisputably a worthy target, if we were to take the MPS data at face value, this has already been achieved between 1984 and 1992 (55% decline in deaths due to medical error from 98,000 to 44,000).

It is unfortunate that the authors of the IOM report chose to use the headline-grabbing death numbers from 2 flawed studies. Use of the death numbers not only undermined the integrity of the IOM’s otherwise strong report but has led health care policymakers to declare solutions based on faulty data.

Richard E. Anderson, MD
The Doctors Company
Napa, Calif

And:

Quoting statistics derived from the Harvard Medical Practice Study (HMPS), Dr Leape and colleagues remark upon “The epidemiologic finding that . . . nearly 100,000 [hospital] deaths occur in the United States annually as a result of mistakes in medical care. . . . ” I believe that authors need to stop perpetuating this number of “100,000 hospital deaths,” a statistic for which there is no valid epidemiologic evidence. This dramatic statistic is largely the by-product of bias introduced by a combination of outlier opinion and the low reliability of physician-implicit review (the method used to produce almost all published estimates of deaths and injuries due to medical errors).

To calculate a valid estimate from the HMPS we would need to know the proportion of cases rated as definitely vs probably vs possibly preventable and the interrater reliability of these ratings. This information has never been made public and our attempts to obtain this information have been unsuccessful. In light of recent research on this topic, the appropriate conclusion is that medical errors are common and result in serious and preventable adverse events, but there is no evidence to support the “100,000 hospital deaths” conclusion. Recent research also suggests that the statistics used to estimate the number of injuries due to medical errors are similarly unsupportable.

Rodney A. Hayward, MD
Center for Practice Management and Outcomes Research
Veterans Affairs Ann Arbor Healthcare System
Ann Arbor, Mich

The Psi Myth

Dr. Dossey avoided, both in his comment and in his subsequent article for the Huffington Post, mentioning his own, favorite “CAM” beliefs. These are easily found on his website and in his books and articles. Examples follow.

From an interview:

Q: In your new book, Reinventing Medicine, you describe three periods in medicine: Eras I, II, and III. Please tell us about them.

A: These eras describe the periods through which medicine has progressed since the second half of the 19th century.

Era I, which can be called “mechanical medicine” and which began roughly in the 1860s, reflects the prevailing view that health and illness are totally physical in nature, and thus all therapies should be physical ones, such as surgical procedures or drugs. In Era I, the mind or consciousness is essentially equated with the functioning of the brain.

Era II began to take shape in the period following World War II. Physicians began to realize, based on scientific evidence, that disease has a “psychosomatic” aspect: that emotions and feelings can influence the body’s functions. Psychological stress, for example, can contribute to high blood pressure, heart attacks, and ulcers. This was a radical advance over Era I.

The recently developing Era III goes even further by proposing that consciousness is not confined to one’s individual body. Nonlocal mind — mind that is boundless and unlimited – is the hallmark of Era III. An individual’s mind may affect not just his or her body, but the body of another person at a distance, even when that distant individual is unaware of the effort. You can think of Era II as illustrating the personal effects of consciousness and Era III as illustrating the transpersonal effects of the mind.

In that book, as reviewed by Victor S. Sierpina, MD, Dossey suggests how “nonlocal mind” will contribute to the practice of Era III medicine:

Reinventing Medicine changes everything. In his latest book, Larry Dossey, MD, has done a masterful job of meticulously documenting the science at the frontiers of medicine while expanding those frontiers even further…

A compelling example is given in the use of all three levels of caring in the “Era III Emergency Room.”

He vividly shows us a new kind of emergency department in which an auto crash patient is not only stabilized and sutured but has the suggestion of relaxation imagery along with the lidocaine and nylon. Meanwhile, caring healers take a moment to pray and visualize a positive outcome based on the scientific evidence of the effects of nonlocal mind, employing a network of nonlocal healers as they work.

For those many doctors now burning out from the challenges of modern medical practice, this new model offers a shining star of hope.

That book was published in 1999, and was mainly a plug for “distant healing”—especially the version known as “intercessory prayer,” in which people are recruited to pray, usually from a great distance, for patients who themselves are unaware of it. Dossey was especially impressed by a study done with AIDS patients as the recipients of prayer, conceived and authored by the late Elisabeth Targ, daughter of conspicuous psychical researcher Russell Targ.

Back on Dr. Dossey’s website, he explains to an interviewer how he came to write his newest latest book, the Power of Premonitions:

I actually tried not to write it. I largely ignored this stuff for years, but this didn’t work very well. My own experiences of premonitions grabbed me and wouldn’t let go. During my first year in medical practice as an internist, I had a dream premonition that shook me up and made me realize the world worked differently than I had been taught. Briefly, I dreamed about a detailed event in the life of the young son of one of my physician colleagues. It turned out to be so accurate it scared me. There was no way I could have known about the event ahead of time.

Then patients of mine began telling me about their own premonitions. Even my physician colleagues would occasionally open up and share their premonitions with me. So I decided this was a well-kept secret in medicine that needed telling.

The time is right for this book because science has come onto the premonitions scene. There are now hundreds of experiments that confirm premonitions, which have been replicated by researchers all over the world. So there’s a new story to tell. It’s no longer only about people’s experiences, but it’s also about science.

Many people still think this stuff is just mumbo-jumbo and that there’s no science to back it up. It’s the “everybody knows” argument — “everybody knows” you can’t see the future, so proof of premonitions cannot possibly exist.

That’s wrong. We now know we can see the future, because that’s what careful scientific studies show…

Take the “presentiment” experiments that have been pioneered by consciousness researcher Dean Radin…

Dozens of these studies have been done by various researchers. They show that we have a built-in, unconscious ability to know the future…

Another type of experiment is called “remote viewing,” in which people can consciously know highly detailed information up to a week before it happens. These studies were pioneered at Stanford Research Institute and have been replicated at Princeton University and elsewhere…

Dossey’s “CAM” fascination, then, has to do with his apparently firm belief in paranormal claims, or psi: purported phenomena such as mental telepathy, extra-sensory perception (ESP), clairvoyance, telekinesis or psychokinesis (PK), precognition, remote viewing, communicating with the dead, and levitation. Dossey’s “nonlocal healing” is merely PK—the notion that a person can exert a force upon an object from a distance, by sheer dint of will—by another name. Is Dossey correct that the only objections to these claims consist of “everybody knows” arguments? Is it true that “careful scientific studies show” such powers to be real? In a word, no.

Although most academic physicians are unaware of it, such studies have been going on for well over 100 years without having yielded a single, repeatable demonstration of such a phenomenon. PK was first tested by Michael Faraday in the mid-19th century, and tested countless times since then. Several parapsychologists themselves admit that “the evidence for psi is inconsistent, irreproducible, and fails to meet acceptable scientific standards.” The history of psi research is also generously sprinkled with fraud.

When such results are considered in the light of prior probability—which they rarely are, as far as I can tell—the reasonable conclusion is not merely that psi remains unproven, although that is the polite thing to say and is what we can know with certainty; the reasonable conclusion is that psi doesn’t exist. Even if we hedge, for politeness’ sake, we must argue that there is no justification for spending public monies on further psi research.

What are some of the prior probability issues? Consider: For ESP there must be a signal and there must be a receptor; neither has been detected or characterized, and the purported signal is not shielded by any known material, including the human bodies that must contain the receptor. Yet there must be shielding material in the receptor, which could otherwise not receive. PK has the same problem, but adds a requirement for receptors in inanimate objects; but the same objects somehow don’t shield a similar signal when they happen to be in the way of another receiver; which further raises the prickly question of how there can be specificity of signal to receptor, to account for such preferential receiving; and for that matter, how is the enormous problem of noise (5-6 billion transmitters and counting) overcome? There also seems to be no diminution of signal strength with increasing distance from the source, contrary to the requirement of the first law of the universe (conservation of energy). I’m sure you can think of more.

Yet psi has been, and continues to be, one of the major “CAM” topics in medical schools, nursing schools, government, and elsewhere. Larry Dossey was one of the authors of the original manifesto presented to the Office of Alternative Medicine, “Expanding Medical Horizons.” That document has been accurately called “an uncritical catalog of virtually every dubious and unproven treatment method of the past 100 years.” Dossey’s co-directors for the “Mind-Body” panel, which called for investigations of “nonlocal therapy,” included psychiatrist James Gordon, who would later chair the White House Commission on Complementary and Alternative Medicine Policy, and “pioneer–legend–crusader” Jeanne Achterberg. Dossey and other psi aficionados have been showered with awards from influential boosters of “Integrative Medicine,” most notably the Bravewell Collaborative.

Wide-eyed book reviewer Victor Sierpina runs the UTMB Integrative Healthcare project, funded by the NCCAM. Elisabeth Targ continued to be funded by the NCCAM even after she was revealed to have dredged data to make her AIDS study look “positive”, true to parapsychology tradition. Columbia University presided over a shady PK study of its own, to add to its “CAM” Hall of Shame. Gary Schwartz, a psychologist who works with Andrew Weil at the University of Arizona, directs the NCCAM-funded Center for Frontier Medicine in Biofield Science. Schwartz has published a book in which he claims to have shown that mediums, including John Edward, can communicate with the dead.

The previously linked articles by Martin Gardner and Ray Hyman show just how tiny and insular this psi clique is. The studies “pioneered at Stanford Research Institute,” touted by Dossey, were done by Elisabeth Targ’s father, Russell. Astral voyager/remote viewer Marilyn Schlitz is a former member of the NCCAM Advisory Council, as is naturopath and Targ co-investigator Leanna Standish. And so on.

Psi in “CAM” is not limited to “distant healing” or precognition. Therapeutic Touch, Reiki, and External Qi Gong are each examples of psychokinesis, as is almost every other example of “energy medicine.” So are some aspects of “applied kinesiology,” so beloved by chiropractors and others. But, as Rob Cullen might say, enough already.

Conclusion: The “Let us Ruthlessly Apply Science” Myth

It is tempting to say that Dossey is disingenuous, or even dishonest. He certainly knew enough about the parapsychology literature back in 1992 to realize that the game was already over for PK. Yet he promoted it, in the Expanding Medical Horizons document, as though it was a revolutionary new idea whose time had barely begun, without offering dissenting citations (that is, without “ruthlessly applying science.” Did he count on physicians, biomedical scientists, and NIH administrators being completely ignorant of the history of parapsychology, or did he just get lucky?). Yet I’m not so sure. Even now, well after the several large, unnecessary “distant healing” trials have yielded their predictable results, his faith is unwavering. He seems to be a true believer, in the truest sense of the term, even as he continues to avoid genuine confrontation with rigorous arguments that contradict his beliefs.

Does he also believe that he is as committed to science as he claims in his response to Dr. Val? I don’t know, but such language is stock-in-trade for “CAM” pushers. A double standard, ya think? Surprise: some of them have now confessed to the practice. Here is the abstract of a recent article titled “The need to act a little more ’scientific’: biomedical researchers investigating complementary and alternative medicine“:

Abstract: The advent of scientific research on complementary and alternative medicine (CAM) has contributed to the current state of flux regarding the distinction between biomedicine and CAM. CAM research scientists play a unique role in reconfiguring this boundary by virtue of their training in biomedical sciences on the one hand and knowledge of CAM on the other. This study uses qualitative interviews to explore how CAM researchers perceive and negotiate challenges inherent in their work. Our analysis considers eight NIH-funded CAM researchers’: (1) personal engagement with CAM, (2) social reactions towards perceived suspiciousness of research colleagues and (3) strategic methodological efforts to counteract perceived biases encountered during the peer review process. In response to peer suspicion, interviews showed CAM researchers adjusting their self-presentation style, highlighting their proximity to science, and carefully ’self-censoring’ or reframing their unconventional beliefs. Because of what was experienced as peer reviewer bias, interviews showed CAM researchers making conciliatory efforts to adopt heightened methodological stringency. As CAM researchers navigate a broadening of biomedicine’s boundaries, while still needing to maintain the identity and research methods of a biomedical scientist, this article explores the constant pressure on CAM researchers to appear and act a little more ’scientific’.

Well, OK. Now that we agree that the whole thing is a ruse, can we finally call it off?