Monday, April 25, 2005

How not to win friends and influence people

The question caught me by surprise.

While at the AACR Meeting last week, I was having brunch with a friend I used to work with, whom I hadn't seen in a long time. She and her husband had brought along two of their oldest and dearest friends, whom they had known nearly 50 years, as well as another of my former coworkers. We were idly chatting away and eating, when one of the occupational hazards of being a doctor presented itself. Tthe conversation drifted to medical topics. And then it came.

"What do you think of Dr. Gonzalez?"

Ah, hell.

Blindsided again! Why hadn't I seen that one coming? As a doctor, I find that these sorts of questions hit me when I least expect them. I was half-tempted to play dumb and pretend that I didn't know who Dr. Gonzalez is, but decided against that approach. It doesn't work anyway. I knew feigning ignorance would only result in her telling me who Dr. Gonzalez is. Instead, I asked a single question to make sure we were both on the same page and talking about the same Dr. Gonzalez, "Do you mean Dr. Gonzalez in New York City, the one who uses 'detoxification' to treat cancer?"

"Yes, that's him," she replied.

No escape there. For those of you who aren't aware of who he is, Dr. Nicholas Gonzalez is a physician in New York City who claims to be able to treat incurable cancers with a regimen that includes dietary manipulations, "detoxification" with coffee enemas, and the ingestion of pancreatic enzymes. I've discussed him before in the context of a patient who followed his regimen and paid a price and, indeed, who might even have been treated by Dr. Gonzalez himself. His methods are based on a regimen popularized by Max Gerson. Using this regimen, he claims that he can produce long-term survival in inoperable pancreatic cancer, for which the median survival is usually less than six months. Never mind that his study only had 11 patients who could complete the regimen, had no control group, and, given the rigor of the regimen required, had the potential for serious selection bias (Gonzalez's regimen can sometimes require as many as 150 pills per day). Based on this tiny uncontrolled study, somehow NCCAM saw fit to fund a $1.4 million clinical trial. As I've said before, if I were to submit a grant proposal to the NIH with so little preliminary data, the study section would have a good laugh at my expense before filing my application in the cylindrical file. In fairness, I will give Dr. Gonzalez a modicum of credit for, unlike alties, at least making an attempt to use science to look at his therapy, however dubious the supporting data. Most alties don't make even the pretense of doing that.

I wasn't in the mood. I had just wanted to hang out with some old friends and talk about science, old times, and other topics. Also, I knew that a debunking session would probably not be appreciated (they seldom are, particularly in what was supposed to be a light social situation), and I didn't want to risk offending my friends by being too strident with their old friend. So I tried to discourage her. "You probably don't want to know what I think," I replied, with what I hoped was a self-deprecating smile and chuckle.

"No, I do," she said.

Damn, she's going to be persistent, I thought. Not in the mood for a confrontation, I became more insistent. "No, I really don't think you do."

"Please." She leaned forward.

"You're probably not going to like it," I gently warned her. (If she didn't know what I was going to say now, I couldn't be responsible.)

"Come on."

OK, I warned you. "He's a quack," I blurted out, wincing inwardly at how it must have sounded. "I see no evidence that his 'therapies' do anything for cancer patients." Did you have to use the q-word? Why couldn't you be more diplomatic? I rebuked myself. You know what you normally do in these cases. You normally say that the treatment is unproven, that there is no evidence that it does anything whatsoever to increase long-term survival in cancer patients, but that you doubt it does any harm. (Even if you don't necessarily believe that inside for this particular therapy.) That's how you defuse the situation, avoid unpleasantness, and even possibly educate the people asking about the questionable therapy. You don't use the q-word! (At least, you don't use the q-word with well-intentioned people who just don't know any better. Hard-core alties, on the other hand, are another matter entirely.)

She was silent for a moment. Silverware clinked, but no one spoke. Everyone, my friend included, was looking at me expectantly.

I began a discussion of why I held the opinion I did about Dr. Gonzalez. I was starting to explain that Gonzalez's methods were based on out-dated, faulty, turn-of-the-century concepts of how cancer developed, how there is no good randomized clinical study that shows his methods do anything for cancer patients, and how the only reason his methods hadn't gone the way of Laetrile was because of aforementioned tiny study, which led to the NCCAM study, when my friend's friend interrupted. "You know, my husband and I know one of Dr. Gonzalez's patients."

"Oh, really," I said. So that was why she was so interested.

"Yes, he had melanoma. His doctors told him he should just go into hospice or go home to die. But he went to Dr. Gonzalez, and he's been fine. That was 12 years ago."

Ah, geez. The dreaded "the doctors sent me home to die" cliché of so many alternative medicine cancer cure testimonials--even worse, the testimonial told second-hand to a friend. You can't effectively fight that one without risking serious unpleasantness, and I didn't want things to get too unpleasant, in deference to my friends. I realized that there was no way I was going to convince these people that Gonzalez was using unproven methods with no evidence of efficacy. They believed he had saved their friend's life when no other doctor could. I also realized that questioning them to see if I could figure out whether their friend really did have metastatic melanoma was probably pointless. I guessed that most likely their friend probably didn't have stage IV melanoma and that surgery probably took care of the disease, as it does for the vast majority of melanoma patients who survive the cancer. But people won't believe that or hear it when you say that. (In my experience, lay people rarely have enough information to let me assess the true severity of their friend's or relative's illness.)

So I did the only thing that was left to me. I explained that a single anecdote does not constitute evidence for general efficacy, using one of my favorite sayings, "The plural of 'anecdote' is not 'data.'" I also explained that spontaneous remissions, although very rare, do occasionally occur for melanoma and that it was impossible to assess whether the Gonzalez treatment really worked or whether conventional surgery had taken care of the melanoma. (Remember, when patients undergo surgery and then decide to opt for alternative medicine for the remainder of their treatment, they almost always attribute their "cure" to the alternative medicine, and not to the surgery.) Finally, I pointed out that my skepticism was rooted in both the lack of evidence that Gonzalez's therapy does any good and the flawed "model" of cancer upon which the Gonzalez therapy is based. I told them that it was being studied in a clinical trial but that I sincerely doubted that it would be shown to have much, if any, benefit. I also explained the concept of selection bias, and how the healthiest patients were the ones who could manage to go through Gonzalez's rather rigorous regimen, which could include as many as 150 pills a day.

"Oh," she said. "You know, I heard of another person that Dr. Gonzalez had turned down because he had had so much chemotherapy and other treatments before."

"That doesn't surprise me and only makes me think selection bias even more," I replied.

Perhaps I had gotten through after all--maybe just a little. It also helped that everyone at the table except them were scientists involved in medical research. I got a little tactical air support from them.

The conversation moved on to other topics. I did see everyone again a couple of more times while in Anaheim, and, to my relief, the topic of Dr. Gonzalez never came up again.

But this encounter reminded me of a few things. First, credulity will hit you when you least expect it. Most people who believe in these things aren't alties. They are regular people who just don't have the background in science and critical thinking to assess claims of "unconventional" practitioners properly. Second, many of these people can be educated, but not by stridency or overly strong attacks on their favored practitioner. That's why I winced when I let it blurt out that I thought Dr. Gonzalez was a quack. That could have turned them off so completely that anything else I said would have been discounted. (Fortunately, it didn't, but it could have.) Finally, if you're a skeptic and a doctor, you have to be prepared at any moment to do your part for evidence-based medicine and against unproven and/or ineffective remedies. And remember, don't resort to bluntness until you've exhausted more diplomatic means of getting your message across--unless you're dealing with an altie, of course.

10 example(s) of insolence returned:


At 4/25/2005 9:18 AM, Blogger HaloJonesFan said...

It's the old "eyewitness testimony" problem. This person does not care what you think, or explain, or even demonstrate incontrovertibly to be true--they know what they saw, and that must be how it happened.

 

At 4/25/2005 9:49 AM, Anonymous Judy said...

Well, as the saying goes, "If it walks like a duck..."

I see your point about not turning people off by being blunt, but if the people around you know that you almost never talk that way, then it may actually INCREASE your effectiveness on those rare occasions when you do.

Besides, he is a quack.

 

At 4/25/2005 10:51 AM, Anonymous Mark Paris said...

You displayed some restraint, at least when it came to talking about the anecdote. I learned fairly late in life that people sometimes actually lie about things like that. Just imagine: someone's testimony might actually be untrue, not just that single, unusual, actual occurrence.

 

At 4/25/2005 1:32 PM, Anonymous Anonymous said...

Great post! I particularly liked "The plural of 'anecdote' is not 'data.'" You could have sat and traded anecdote for anecdote with them, but the approach you took was the one that led to real education.

-Ali

 

At 4/25/2005 2:04 PM, Anonymous madbard said...

Thanks for the posting, Orac. I'll need to remember some of that tact (and tactics) for my next dubious science encounter.

 

At 4/25/2005 2:38 PM, Anonymous Anonymous said...

Ye gods! I can't believe the NIH is funding that study or that any IRB is allowing it. It's a phase III trial? Where are the phase I and II results? Shouldn't people with stage II disease at least be evaluated for definitive surgery rather than being shunted off into this nonsense? I thought the NIH Had better sense than this.

 

At 4/25/2005 2:56 PM, Anonymous Tom Wigton said...

Thanks. I walk into these traps with patients, especially those with multiple pregnancy losses, who seek an opinion after having seen the "specialist" who advises all sorts of unproven, costly interventions; and promises a good outcome only if they follow his "rules". And there I am, trying to talk them down, explaining the risks and alternatives, and of course, the lack of data which demonstrates any benefit. And I'm the bad guy.

 

At 5/03/2005 1:32 AM, Blogger Carrie said...

Great post. Odd timing in light of this news aired today about a former Toronto, Ontario, newsman and activist.

He was a co-founder of Greenpeace, Bob Hunter, and he died today after a long battle with prostate cancer. Interestingly enough, after battling nuclear testing during his career, he did undergo radiation as part of his treatment. Then he went to a clinic in Mexico, probably the one you're referring to, and it was a big deal in Canada when he did that. A huge write up in the Toronto Star about his treatment and the clinic. And now, today, he's gone.

If that isn't proof that quackery can't be trusted I don't know what is. Here's a link to news on his death from his employer, CityTV in Toronto - http://www.pulse24.com/News/Top_Story/20050502-013/page.asp

 

At 5/03/2005 1:39 AM, Blogger Carrie said...

Sorry, link cut off partially -
http://www.pulse24.com/News/Top_Story/
20050502-013/page.asp

 

At 5/03/2005 6:12 PM, Anonymous Anonymous said...

My husband is an ob/gyn and it is so hard to bite my tongue when someone starts waxing poetic about some of the other ob/gyns in this area, some of whom, frankly, should not be allowed to deliver a pregnant lab rat. It's really a lose-lose situation and I'm not even the doctor! If I gently try and explain why Dr. Fabulous is not so fabulous, it's assumed that I'm just drumming up business for my husband or his partners. Or, I risk revealing something that I'm probably not even supposed to know. Now, I just smile politely and play dumb. Unless it's a dear friend and a life or death situation, I just let it go.

 

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