September 26, 2002Kimball Atwood, M.D. xxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxx
I have now had time to look into the allegations in your letter of June 14th which, incidentally, I shared with Dr. David Eisenberg and he with several others. I have sought consultation about our exchanges and the gist of my response follows.
Some of your concerns and allegations are very helpful and constructive. Perceptions are particularly important in controversial fields where there is limited objective proof. Your cautions and interpretations in this area have been very useful to us.
Some of what you said is just plain wrong. This includes the allegation the Harvard has “a stake” in the area and therefore would not look into your allegations objectively. Relatedly, Dr. Howard Koh has written us a construction of the events in the Massachusetts Special Commission that is strikingly different from yours. And Dr. Anthony Komoroff has pointed out that many of your comments about the InteliHealth treatment of CAM are now grossly out of date as the material inherited from another provider has been reviewed by HMS faculty and modified. [Indeed, you have referred in other correspondence to modifications you have noticed.] Dr. Komaroff also commented on the misleading way your citation the treatment of homeopathy was disconnected from the rest of the paragraph.
Some of what you said is a matter of taste or interpretation, where even well intentioned people may disagree. In this particular area I have weighed your arguments carefully and, in places, learned from them.
But I think the biggest difference may be in a misperception about what our purposes are. The Council of Academic Deans of Harvard Medical School approved beginning a Division of Research and Education in Complementary and Alternative Therapies with exactly the focus described. Our goal is to do peer-reviewed basic and clinical research on the claimed, but unproven, efficacies of complementary and alternative approaches to therapeutics. The recent scientific sessions and requests for proposal held by the Division are clear testament to this intent. In addition, in common with the Association of American Medical Colleges and most of the allopathic schools of medicine, we intend to teach our students something about CAM and in particular how to assess its claims rigorously. We do not, repeat NOT, have any intention of making our students CAM practitioners. They have enough to do learning what we have always focused on.
Daniel D. Federman, M.D.
cc: David M. Eisenberg, M.D.
October 5, 2002Daniel Federman, M.D. Senior Dean for Alumni Relations And Clinical Teaching Carl W. Walter Distinguished Professor Of Medicine and Medical Education Harvard Medical School 25 Shattuck St. Boston, MA 02115
Here is a point-by-point response to your letter of September 26, 2002.
Your assertion that I made “the allegation that Harvard has a ‘stake’ in the area and therefore would not look into your allegations objectively” is a straw man. Consider that if I had truly believed that, why would I have bothered to press the matter? The only written content that I can find regarding this is in an email to you on or around 11/20/01, shortly after you had told me on the phone that “we have made a big investment in David.” Here is what I wrote:
I’m confident that if you were to examine the issues as comprehensively as I have you would agree, but I also know that there is a powerful desire not to accept that a mistake has been made (a big investment, and all that), and that you would rather not spend your time on this (nor would I).
My concern at that time was not that you might not look into the matter objectively, but that you might not look into it at all. My reasons—the “powerful desire” and time constraints—had to do with human nature, but not with any suspicion of malfeasance. Later, when we met in your office, you made it clear that you were miffed by the mere suggestion that you might not pursue the matter. I don’t remember what I said, but I’m certain that I accepted your assurance.
The Special Commission
Now, regretfully, I must reconsider. At the time that we met, you told me that my points regarding Dr. Eisenberg’s role on the Special Commission were enough to warrant convening an ad hoc committee to look into the matter. Apparently, no such committee exists. Instead, you “shared my allegations with Dr. Eisenberg and he with several others.” You agreed when we met that the mere presence of Dr. Eisenberg on such a Commission was curious, in light of the professed purpose of the Division: “research and education.” You were also surprised that Dr. Eisenberg had hired a “Director of Legal Programs,” and you agreed that the existence of such a position was disturbing. You were especially concerned that Atty. Cohen, who is not a physician and whose writings reveal an antagonism to modern medicine, had been the de facto representative of the Massachusetts Department of Public Health to the Special Commission while carrying the HMS imprimatur. Implicit in our discussion was the problem of Dr. Eisenberg having dragged the HMS name into a political quagmire without having first consulted you or Dean Martin. In all of this we were in agreement, even if we disagreed about some other aspects of the HMS “CAM” program.
You also agreed, I thought, that Dr. Eisenberg’s acceptance of funds from the Southwest College of Naturopathic Medicine, as he sat in judgment of naturopaths’ aspirations, was a conflict of interest. He did not disclose this arrangement to the Commission. In the essay that I sent you in March, revised in June, I called attention to several other conflicts of interest, of which at least two—funding by the Fetzer Institute and by the NCCAM—bore directly upon the work of the Commission. I left unsaid, but implied, the reciprocal point: that if Dr. Eisenberg ever gets around to investigating the actual practices of naturopaths and other dubious practitioners, his conclusions will be subject to impeachment both because of these conflicts and because of such a political foray. This is hardly consistent with the goals that you state in your letter. Yet you mention none of these points, as though they do not exist. Although I did not think so before, I now doubt that this issue has been investigated objectively.
Dr. Koh did not come to Commission meetings, so it is difficult to imagine that he could have offered a “construction of the events” at all, much less one that is strikingly different from mine (unless, of course, he got his report from someone who was there). There are questions that Dr. Koh might answer: how did Dr. Eisenberg get the job? Did Dr. Koh know that Dr. Eisenberg had called for the nationwide licensure of naturopaths, the very issue that would face the Commission, three years prior to its inception? Did Dr. Eisenberg disclose his conflicts of interest to Dr. Koh? Was Dr. Koh aware of Dr. Eisenberg’s allegiance to Fetzer and its “credentialing program?” What did Dr. Eisenberg tell Dr. Koh about Atty. Cohen? Did Dr. Eisenberg ever discuss naturopathic practices, or the public health implications of licensing naturopaths, with Dr. Koh, even though he refrained from doing so at Commission meetings?
Did Dr. Koh ever read my correspondence to him, in which I explained absurd naturopathic claims and charged that Dr. Eisenberg appeared inadequate to the task of protecting the public health? How could Commissioner Koh have allowed such an anti-public health report to be signed by his representative? To what extent did the influence of Assistant Commissioner Nancy Ridley, the powerful but naïve functionary who admitted to me that she was bedazzled when visiting the Dana-Farber “CAM Fair” with her ill mother, figure in this decision? While interesting, these questions are distinct from the facts of the Commission itself.
The facts are these: Dr. Eisenberg represented the DPH at the Commission, much of the time surrogating Atty. Cohen. The two were laden with conflicts of interest that they did not disclose. In the end the Commission produced a report that, if approved by the legislature, would amount to official endorsement and protection of quackery. According to the Commission’s Chairman, Dr. Eisenberg and Mr. Cohen helped to write the report. Ms. Ridley, who replaced Dr. Eisenberg at the final meeting for reasons unknown to me, signed the report. All other details, including Dr. Eisenberg’s and Atty. Cohen’s contributions (and lack thereof) at the meetings, my correspondence with Dr. Eisenberg, and the secret and possibly illegal proponent sessions that occurred during the summer of 2001 are at least as embarrassing to Harvard Medical School but are unnecessary to make the case. If you had been interested in a corroboration of my account, most of which is a matter of written record, you could have consulted Drs. Relman and Madras.
Regarding InteliHealth, none of my comments were out of date when I wrote them, and none are “grossly” out of date even now. According to the website, Harvard’s affiliation began in August 2000. The first of the changes to which Dr. Komaroff refers, i.e., to the articles on chiropractic, homeopathy, and naturopathy, occurred in March 2002—several weeks after I had called your attention to the articles. I acknowledged the changes as soon as I saw them. InteliHealth itself, however, did not utter so much as an “oops.” The former treatises had been on the website, according to the copyright, since 1997. As soon as the HMS faculty “reviewed and modified” these, it should have warned hapless readers that they had been duped for the previous five years. When I queried the website wondering what had happened, the reply was a bland “our vendor has changed.” There was no mention that the previous information had been erroneous and dangerous.
Other, very recent changes on InteliHealth were made not because of any review by Harvard faculty, but because of complaints made by Stephen Barrett, the acerbic editor of Quackwatch. One of these involved the recommendation by Ms. Wetzel to “find a doctor who understands complementary and alternative medicine” by consulting the American College for Advancement in Medicine (ACAM). As I explained to you in January and also in my essay, this organization is, and has been for more than 25 years, a front for chelationists. In 1998 the FTC barred the ACAM from advertising EDTA chelation as effective for atherosclerosis. This is common knowledge to anyone with an interest in aberrant health claims. Dr. Barrett correctly observed, in his email to InteliHealth, that “referring readers to ACAM members is like referring people who want to borrow money to Mafia loan sharks.” Dr. LeWine replied that the real agenda of the ACAM had been unknown to the Harvard reviewers, including “experts in CAM,” who were still unable to discern it even when they perused the ACAM website after being tipped off by Dr. Barrett. These reviewers are not experts; they are innocent of the realities of “CAM.”
For Dr. Komaroff’s information, if a patient with chronic fatigue syndrome were to find a doctor through the ACAM, he or she would likely be advised that the syndrome is caused by candida overgrowth and “toxins,” including routine childhood immunizations and “conventional” pharmaceuticals, and that the appropriate therapies are enemas, intravenous EDTA and expensive “supplements,” all hawked by the practitioner, and the cessation of rational medicines. Surely Dr. Komaroff must be aware of these and other fraudulent claims made by ACAM past-president Murray Susser, the convicted quack who is also the President of the American Association of Health Freedom (AAHF). Recall that it is the latter organization upon whose advisory board sat Atty. Michael Cohen, the “Director of Legal Programs” for the HMS “CAM” program.
I reiterate that the new InteliHealth articles are not much better than the old. Here is another example, deleted only last month after another complaint by Dr. Barrett:
Naturopathic practitioners can address most health problems but acknowledge that some serious medical problems (such as life-threatening illnesses, childbirth emergencies and broken bones) are best treated by conventional medicine.
Harvard’s reviewers apparently aren’t aware that naturopathic practitioners have had no post-graduate training, even if the same reviewers imagine that naturopathic undergraduate “training” is equivalent to that found in real medical schools. Even without this passage, the remaining article on naturopathy is unacceptable. With misinformation like this in the public domain, it’s no wonder that legislators are so willing to wish pseudomedicine upon the public.
The new chiropractic article is aptly named: “Fact and Fiction about Chiropractic.” This is about right, because the article contains similar doses of each. Ironically, an excellent article on chiropractic, written by one of its own practitioners, appeared on Medscape a little more than a year ago. It was favorably reviewed by a group from the BIDMC that did not include the usual “CAM” proponents. A link to this article would have been the perfect solution for InteliHealth.
Dr. Komaroff worries that I misled by selectively quoting from the homeopathy article (presumably the new one). It is true that some of the sentences in that article are, in and of themselves, reasonable. The article as a whole, however, is misleading and irresponsible. I could have quoted it in its entirety to even greater advantage, but in the interest of brevity I did not. I would be happy to comment on this or any other InteliHealth “CAM” article, if the editors are truly interested in expert opinion that can be trusted.
Taste vs. Science
You write that some things are a “matter of taste or interpretation, where even well intentioned people may disagree.” This is obviously true, but there is more than one point involved. “Well intentioned” is not the same as “informed,” and in medical matters the latter characteristic is at least as important as the former. I’m quite sure that most homeopaths believe in what they do; I’m equally sure that some academic physicians, who think that homeopathy is merely “unproven” and “might work,” are sincere. They are wrong, however, and this is not a matter of taste or interpretation.
To prove this to yourself, substitute “a perpetual motion machine” for “homeopathy.” Both violate the same fact of nature, as demonstrated by every chemical reaction, nuclear reaction, biological process or physical change that has ever been observed and measured, every engine that has ever been designed, every electrical circuit that has ever been constructed, and numerous other phenomena. To think that this law can be overthrown by a whimsical pre-scientific notion that has no explanatory power in nature and that offers only the flimsiest of “positive” clinical evidence, all of it easily explained by well-established sources of error, is laughable. You yourself told me, almost sheepishly, that you didn’t believe in homeopathy. Why not? There are scientific principles involved in the interpretation of this and all other “CAM” claims. One oughtn’t be afraid to use them.
Your final paragraph suggests that we’ve gotten nowhere. You seem to conclude that my main point, that the HMS “CAM” effort promotes absurd and dangerous medical claims, was a “misperception.” Was Dr. Eisenberg’s role on the Special Commission a misperception? Was my reading of the appeal on the Harvard/BIDMC CAMRE website, that anonymous readers should find “naturopathic physicians” and other dubious practitioners through the yellow pages, a misperception? I don’t think so. Nor was the recommendation, on the same site, for a book about “alternative” cancer therapies that praises coffee enemas, “medical intuitives” (psychics), and “anti-neoplastons.” Nor was the article featuring an idyllic picture of a chiropractor performing a cervical spine “adjustment” on a nine-month-old baby. Nor was the brochure in which the reader is exhorted to call the Center for Holistic Pediatric Education and Research at Children’s Hospital for “a list of pediatric homeopaths in the Boston area.” Nor is the exuberant flyer, from the same Center, announcing an “Expo” in June 2002 featuring Therapeutic Touch, “craniosacral,” Reiki, acupuncture, reflexology, and a “free raffle for a holistic treatment.”
Need I go on? I have no doubt that these promotions were not the intent of the Council of Academic Deans. That is exactly why I approached you in the first place. Perhaps my misperception involves the question of whether they emanate from the “Division” per se. I don’t dispute this point, but it is irrelevant.
The results of such “misperceptions” are potentially catastrophic, but probably unmeasurable. If there are sporadic deaths from asthma, or if a few excess cases of rheumatic heart disease or subtle hearing loss occur because of such mischief, who will notice? How many more families will be left to feel guilty that they didn’t discover “guided imagery” in time to save their loved one from cancer? No one, least of all at the Division, is counting.
Equally insidious is a possibility that Atty. Cohen hinted at during Commission meetings: that physicians who don’t refer patients for “CAM” methods will face malpractice suits or disciplinary measures. I didn’t take it seriously at the time, but I would have if I had known about Mr. Cohen’s involvement with the AAHF. Recall that the AAHF filed an amicus curiae brief supporting a malpractice case of exactly this sort, involving a fanciful treatment (“anti-neoplastons”) that has not been subjected to clinical trials. Imagine what might be done with “distant healing” or homeopathy, methods that are also useless but whose proponents have learned to cite equivocal conclusions from error-laden trials and reviews in which prior probability is ignored. Dr. Komaroff could be found negligent for not arranging for anonymous intercessory prayer or hand-waving over a CFS patient; you could be sued for not prescribing a nonexistent dose of mannitol, or a nonexistent piece of pizza, to a patient with diabetic ketoacidosis. Don’t laugh; the real-life example above is no less outrageous.
CAM Research at HMS
The research of which you write has been, so far, elusive. One finds a couple of useful papers from the BI in the early ‘90s, one a review article failing to find efficacy for biofeedback and meditation in hypertension, the other an original study failing to find physiologic correlates to subjective impressions of the “relaxation response.” Since then almost all “CAM” studies emanating from Harvard have consisted of surveys of “CAM” use or attitudes. As previously explained, the most notorious of these were funded by the Fetzer Institute and were misleading, incorrectly interpreted, and used by “CAM” enthusiasts, including the lead author, to push a political agenda. Others presented useful data that should have warned their authors of the folly of dalliances with quacks. This has been clear, to those who pay attention to such matters, throughout the history of medicine. Among those warning of it were some of the most illustrious members of the Harvard Medical School faculty. In the post-modern era of “tolerance,” however, the wide-eyed ingénues of academic “CAM” imagine that theirs is the first such experience, and believe that they can induce pseudoscientific practitioners to become responsible just by being nice to them.
Other articles emanating from the Harvard “CAM” effort are not studies at all, but are deferential apologies for various irrational “CAM” practices. These are misleading to the point of dishonesty, as I have previously explained. An example is a treatment of chiropractic in which the authors obfuscate the core claim of the field (“subluxations”), ignore prior probability when considering chiropractic for conditions other than back pain, minimize the risks of cervical spine manipulation by failing to report that it is usually repeated tens or even hundreds of times, ignore chiropractic’s widespread anti-vaccination and anti-pharmaceutical stance, neglect to mention the preponderance of other quack methods favored by chiropractors, and fail to note that those chiropractors who have renounced the irrational tenets of the field represent only a tiny fraction of the whole.
Curiously, the authors offer an apt description of quackery without seeming to recognize it: “They never fail to find a problem. By rooting pain in a clear physical cause, chiropractic validates the patient’s experience.” Whether this represents naïveté or defiance on the part of the authors is unclear, but it seems to mock the ethical integrity that has characterized the best of modern medicine. Are we to conclude that medical doctors should learn to be so dishonest, in the interest of appealing to patients’ quests for certainty? Or is such deception acceptable only for “CAM” practitioners? The authors end by congratulating chiropractors for “words and deeds of connection and compassion,” which in most cases amounts to nothing more than slick salesmanship.
As for actual research into the safety and efficacy of methods, there hasn’t been much. There was a recent article failing to demonstrate that an “energy healer” could make a real diagnosis by waving his hands near a blindfolded patient. Its authors concluded: “This study points to further need for fair yet rigorous assessment of claims that energy transfer can lead to accurate clinical diagnoses.” There was a well-controlled study from Children’s Hospital that failed to find efficacy for acupuncture in postoperative nausea. I called attention, in the homeopathy piece that I sent you, to a disturbing study in the Pediatric Infectious Disease Journal, co-authored by the director and co-director of the HMS “CAM” effort. A table in that article presents, in a nutshell, much that is wrong with both “CAM” research and “integrative medicine.” I would be happy to discuss it with you further.
I don’t pretend that this is an exhaustive list of “CAM” reports emanating from HMS, but it is a representative overview.
“CAM” for Medical Students
Your mention of the AAMC initiative for the teaching of “CAM” deserves comment because it, along with your use of the term “allopathic” to describe modern medicine, betrays your own naïveté. While it is certainly true that medical students should become aware of “CAM” claims and how to evaluate them critically, the AAMC initiative is unlikely to accomplish that goal. Rather, it will entice students with the same sort of relativistic, “differing paradigms” and “other ways of knowing” rhetoric that is already standard for academic “CAM.”
I have previously called your attention to a survey of medical school “CAM” courses, which found that the overwhelming majority are promotional and uncritical. In the latest issue of Academic Medicine is another survey that came to the same conclusion. In this “theme” issue are several other articles that address the subject. Those by Astin, Maizes et al, Konefal, and Gaudet and Snyderman are erroneous or naïve, but are representative of prevailing opinion within academic “CAM.” The article by Brokaw et al and the letters from Beyerstein, Grollman, Marcus and Sampson are accurate and revealing, but it is not the latter group that is winning the battle for discussions of “CAM” claims on campuses.
That battle is being won by the “Consortium of Academic Health Centers for Integrative Medicine,” of which HMS is a participant. The Consortium was originally bankrolled by the Fetzer Institute, and its most vocal proponent is Andrew Weil, whose “Arizona Program” is considered the model for the rest. Weil is hardly the mentor that a thoughtful dean would wish upon medical students. As psychologist Barry Beyerstein* explains,
[I]t was the realization that shortcomings of perception, reasoning, and memory incline us toward comforting, rather than true, conclusions that led the pioneers of modern medicine to substitute controlled observations and formal logic for the anecdotes and surmises that can so easily lead us astray. This lesson seems to have been lost on proponents of CAM. Some, such as Andrew Weil, reject it explicitly, advocating what Weil calls “stoned thinking,” a mélange of mystical intuition and emotional satisfaction, for determining the validity of a therapy.
Let the student and patient beware. That Harvard might be different is not likely, as I discussed in the essay on homeopathy. Harvard is in the Consortium. The Harvard faculty involved in this effort is out of its league, as evidenced by the comments on InteliHealth above and by almost every other point made in all that I’ve sent you.
Here is a simple plan that would teach HMS students an enormous amount about “CAM” in a reasonable time, would be fun for them, and would provide them with the most accessible and readable reference for any new CAM claim that comes their way: announce, on the first day of medical school, that the recommended initial source for “CAM” information is Dr. Barrett’s site, Quackwatch. Please reject, and help the students get over, the childish notion that if the name is provocative, the content can’t be worthy. I have previously described to you my surprise at finding that one of the directors of the CAMRE had never heard of Quackwatch, which in itself is an indictment of the promise to “assess claims rigorously.” Dr. Barrett has been investigating and writing about “CAM” since long before it was called that, far longer than any of the current crop of academic “CAM” enthusiasts. He is one of the world’s experts on the topic, as Dr. LeWine can attest.
In addition to this, if a course is planned, offer Schick and Vaughn’s How to Think about Weird Things: Critical Thinking for a New Age or some equivalent short introduction to critical thinking (if this had been taught in 1976, HMS might have been saved from itself). Other useful references are Milton Rothman’s The Science Gap and Robert Park’s Voodoo Science: the Road from Foolishness to Fraud, two readable books by physicists that expose the folly of not applying established facts to questionable claims, including much of the content of “CAM.” The latter book also describes how well-meaning individuals who begin with an ingenuous fascination for things that they don’t understand can, quite gradually and almost imperceptibly, travel the road referred to in the title.
Other useful treatments of “CAM” are found in the Scientific Review of Alternative Medicine, available in the Countway Library, and on the following websites: the National Council Against Health Fraud, the American Council on Science and Health, the Entirely On-line Alternative Medicine Primer, the Alternative Health Dictionary, and the Skeptic’s Dictionary of Alternative Health Practices.
Students should also be alerted to the large overlap between paranormal claims (e.g., psychic powers, astrology, and “alien abductions”) and much of “CAM.” Two good sources for this are the Skeptical Inquirer magazine and the James Randi Educational Foundation. Randi, you might recall, is the magician who helped the editors of Nature investigate Benveniste’s homeopathy claim. He has also visited China several times and in 1988 exposed apparent demonstrations of psychokinesis by “Qigong masters,” the same sorts of feats that had beguiledDrs. Eisenberg and Benson, as simple conjuring tricks. Perhaps unaware of this, Dr. Eisenberg continued to be fooled by magical Qigong feats.
Finally, a more advanced treatment of academic “CAM” might include issues that also apply to evidence-based medicine in general. Among these are the pitfalls of systematic reviews and the inadequacy of “P” values, in the absence of considerations of prior probability, for answering questions about how nature works. Students already grounded in the details of “CAM” claims by virtue of having read Quackwatch and other introductory literature will have little trouble seeing through the language and fact distortions that characterize many “CAM” articles in mainstream medical journals, as typified by the article on chiropractic discussed above. Thus they will be able to distinguish reason from propaganda in such places as the “theme” issue of Academic Medicine already mentioned and the current “CAM” series in the Annals of Internal Medicine. In this the students will have quickly surpassed most of their teachers, who tend to be innocent of these realities.
All of these suggestions would make for fascinating learning. They would also help medical students hone their critical thinking skills and impress upon them the importance of scientific literacy, not only for issues in medicine but for things in general.
Your emphatic statement that “we do not, repeat NOT, have any intention of making our students CAM practitioners,” is a red herring. I never claimed that this was your intention, so why the protest? When Dr. Eisenberg made the same point at the Special Commission, however, his explanation was similar to yours: that there isn’t enough time for it. The question left hanging is a disturbing one.
In conclusion, your letter ignored or misrepresented most of the points that I had previously made and have reiterated here. In particular it ignored the numerous promotions of pseudomedicine. It also ignored the relationships that exist between the leadership of the HMS “CAM” program and various ideologically biased donors and dubious practitioners and politicians, including veterans of the Laetrile wars. It is understandable, if unfortunate, that some of the players in this game are necessarily subject to political pressures, however incompatible with good medical judgment those pressures may be. This is true of the NCCAM, for example, and also of the Massachusetts Department of Public Health. Universities are supposed to be different.
The term “ivory tower,” though maligned in recent times, has a noble pedigree. It implies that those within are protected, in their search for truth, from the political and financial influences that inevitably distort all other public discourse. It would be naïve to think that this tower is impenetrable. Nonetheless, it makes no sense to smash holes from within by making bargains with the like of Fetzer, Osher, the American Specialty Health Plans, the AAHF, naturopaths, and Rep. Dan Burton.
Eventually, this chapter in the history of HMS will be remembered with chagrin. Please reconsider now.
Kimball C. Atwood, M.D. HMS Class of 1979
Cc: Arnold Relman, M.D.
Peter Madras, M.D.
*This post is dedicated to the memory of Barry Beyerstein.
†The Harvard Medical School series: