The New England Journal of Medicine blows an opportunity

I don’t know what it is, but most of the journals I subscribe to always seem to arrive on the same day or two, and my secretary puts them in a big pile in my “In” box. Sometimes, when I’m busy and don’t get a chance to peruse them and decide which articles are worthy of attention, they pile up quite impressively in a surprisingly brief period of time. Today, oddly enough, I happened to have some time to plow through the backlog of journals, and that is when I picked up the October 6 issue of the New England Journal of Medicine, fresh off the presses.

And almost dropped it when I saw the Table of Contents. Could it be?

Yest it could, right there, and article entitled Faith Healers and Physicians—Teaching Pseudoscience by Mandate, by Robert S. Schwartz, M.D., a deputy editor of the NEJM. Finally, I thought, an article in a prominent medical journal that makes a connection between teaching pseudoscience like "intelligent design" creationism and quackery. It started with a snarky tone appropriate for addressing attempts by activists to promote the teaching of ID in public schools. Still, it's not a tone that I normally associate with NEJM articles:

In the 1939 movie The Wizard of Oz, Frank Morgan plays five roles. In one of them, he is a flimflam hawker of trivia traveling across the plains of Kansas in a horse-drawn wagon. In another, he is the wizard who, concealed by a curtain, manipulates a machine that controls all of Oz. Now, more than 65 years later, another pitchman is rolling across Kansas, but unlike Morgan's bumbling peddler of trinkets and dreams, the new one has no interest in such trifles. It is an articulate and sophisticated anti-evolution movement called "intelligent design." At its core is the idea that a supernatural being — a hidden wizard — has a hidden hand in shaping the living world.

I like it. I might have to steal it someday and use it for my own nefarious ends. So far, so good, I thought, happy to see a major medical journal stand up for science against pseudoscience. I continued reading, hoping that Dr. Schwartz was working towards the point that I hoped he was working towards. He was:

The debate has been prominent in the press and major scientific journals, but it has not been featured in medical journals, nor has it been discussed publicly by leaders of academic medicine or professional medical societies. Some might ask why physicians should care about how we educate our children, and what difference it would make to medicine if we taught children intelligent design as a counterweight to evolution — which, according to the proponents of intelligent design, is a mere theory. But acquiescing to this anti-science movement would have far-reaching consequences for the development of future generations of physicians, for the likelihood of discovering new therapies, and for understanding health and disease.

Exactly. Dr. Schwartz hit the nail right on the head. Even leaving aside the more specific arguments of how the theory of evolution helps us understand human disease and pathogens, acquiescing to anti-science would indeed have far-reaching negative impacts on a variety of areas. Moreover, I was rather surprised that Dr. Schwartz even appeared to understand the wedge strategy. In the article, although he did not refer to it explicitly by that name, he did point out the origins of “intelligent design” creationism in old-fashioned Biblical creationism. And he goes right to the heart of why ID is not science. Unfortunately, in doing so, he then went on to make a huge fumble along the way, blowing an opportunity to show exactly how the acceptance of such pseudoscience by physicians and in medical schools might have negative consequences for our understanding of disease and translation of basic scientific discoveries in the laboratory into new therapies for patients:

Some of the supporters of intelligent design are knowledgeable and sophisticated. Phillip Johnson, Professor Emeritus of Law at the University of California, Berkeley, and one of the founders and financial backers of the intelligent design movement, can accurately pinpoint many problems that the theory of evolution has not come close to solving. His criticisms have merit, and his focus on precisely those things that we do not yet know blocks any rational dialogue. But Johnson and his followers always end up in the same blind alley: the problems are too complex to be explained by any proposition other than the existence of an intelligent designer.

Uh-oh. He didn't say what I thought he said about Phillip Johnson, did he?

He did, unfortunately.

PZ will probably grate his teeth even more than I did when he reads the part about Johnson’s criticisms having “merit” (if he happens to see this, that is), but, believe it or not, attributing "merit" to Johnson's arrogant puffery isn’t the biggest fumble Dr. Schwartz makes. Has Dr. Schwartz ever actually read Johnson's writings about evolution? If he did, he should have realized that in actuality Johnson's "criticisms of Darwin" are standard creationist fallacies, based on straw men, quote mining (here, too) and misstatements of what the theory of evolution says, supported by no science. Although Dr. Schwartz is correct about the “blind alley” ID inevitably leads into, he missed a huge opportunity here to point out in the pages of the most widely read peer-reviewed medical journal in the nation exactly how a lack of scientific and critical thinking with respect to one pseudoscience can often be symptom of a lack of scientific and critical thinking with respect to everything, particularly other pseudoscience. Why? As it turns out, Phillip Johnson is also deeply involved with HIV/AIDS denialism, the same pseudoscientific quackery that recently resulted in the death of a child of a high profile AIDS denialist. Indeed, Johnson is a signatory to an open letter that states:

It is widely believed by the general public that a retrovirus called HIV causes the group diseases called AIDS. Many biochemical scientists now question this hypothesis. We propose that a thorough reappraisal of the existing evidence for and against this hypothesis be conducted by a suitable independent group. We further propose that critical epidemiological studies be devised and undertaken.

If you don’t believe me about Johnson's AIDS denialist credentials, go to the Virus Myth site, where he and his writings are prominently featured. Note that the mother of the child who died from her negligence is on its Board of Directors. Consider this lovely fisking of one of Johnson’s more crackpot writings about AIDS, so much like his writings about evolution and "intelligent design." Indeed, Ed Brayton has quipped:

I think he [Johnson] just takes the same article and changes the enemy du jour from "the Darwinian establishment" to "the HIV establishment" or "the AIDS establishment". Phil Johnson is nothing if not a consistent tilter-against-windmills. Whoever he's against, it's a grand conspiracy to hide the truth and, naturally, he's got the Truth™ that the hidebound orthodoxy won't let you hear.

That about sums Johnson up rather nicely. In any case, this lost opportunity damned near sinks the article. How could a deputy editor of the NEJM fail to mention such an important point about how credulous thinking about evolution goes hand in hand with credulous thinking about medical science? Phillip Johnson is a poster boy for exactly the sort of thinking that we don't want to see in our medical students and residents. He is Exhibit A of how poor critical thinking skills and lack of understanding of the scientific method can go hand-in-hand with the acceptance of multiple types of pseudoscience. Dr. Schwartz must be either unaware of Phillip Johnson’s opinions and activism with regards to HIV, or he must have chosen to ignore the topic. (I'm not sure which explanation for this lapse would be worse.) Given the huge problem of non-evidence-based medicine and even outright quackery, Dr. Schwartz could have asked the question: Do you want future generations of doctors to be credulous with regards to the claims of pseudoscientists and quacks? Letting pseudoscience into the science classroom under the guise of a legitimate "alternative to evolution" is certainly one way to undermine a student's ability to learn the scientific method. Not a good thing for future doctors!

Fortunately, Dr. Schwartz tries to redeem himself in the remainder of the article, pointing out that the confusion between faith and science at the highest levels of public education "can hardly be an asset to the pool of applicants to medical schools and graduate schools in the sciences," asking:

What would it mean to take intelligent design seriously at the medical school level? Its proponents tell us that gaps in our knowledge of how living organisms evolved vitiate the theory of evolution. Might we conclude, then, that the cancer cell and its evolution are so complex that a creative designer must be the cause of cancer? But if the designer created cancer, is it against the hidden hand's will to find a cure for cancer? Is it in accord with the plan of the intelligent designer to receive a treatment for cancer? After all, a Jehovah's Witness would rather die than receive a blood transfusion. Yet today more than ever, the profession needs physicians who can channel scientific discoveries to the sick. What effect will pseudoscience-by-fiat have on medical progress?

I think we probably know the answer to that one. Imagine someone like Phillip Johnson as a physician. That's a scary thought if you're a patient. Worse, imagine Johnson as faculty at a medical school. That's even scarier to me as faculty. Yes, it's possible to have a solid grounding in critical thinking in one area but not in others, but if the state mandates the teaching of a pseudoscience in the classes that are prerequisites for medical school, it cannot bode well for the grounding of future medical students in the scientific method and an understanding of basic biology. Indeed, it would tend to blur the line between science and pseudoscience, leading to the scary proposition of more doctors who are like Johnson (Dr. Lorraine Day or Dr. Roy Kerry, for example). We physicians already have more than enough quacks and pseudoscientists, which is why we should be doing everything possible to teach and encourage critical thinking and science education in medical school, college, and, yes, high school. The last thing we need is more pseudoscience in our profession! But what to do? Dr. Schwartz has an idea:

If we accept the premise that it is not in the long-term interest of medicine to disguise a faith-based belief as a scientific discipline and indoctrinate future physicians and scientists in a creed that thwarts the science of medicine, what can physicians do now? It seems to me that leaders of professional societies and prominent academicians should start speaking up. At the local level, doctors are prominent and respected. They serve on school boards, and some hold public office. They are influential teachers. Many have religious affiliations, and they surely know the difference between faith and science. Engaging in a public debate about intelligent design is probably not a good idea; any debate about faith and belief will surely end inconclusively. More desirable are education and acting to protect the profession and the public from pseudoscience. The main need now is to begin to understand what the debate is about and to consider its consequences for the future of medicine.

I’m not so sure that I can be as sanguine about physicians' ability to identify the difference between faith and science. The longer I’ve been involved in rebutting “intelligent design” creationism, the more I’ve come to realize that there are actually quite a few doctors who buy into it, or who at least seem to think there’s no harm in teaching it in science class as an “alternative theory” to evolution. One prominent example is Bill Frist, a Harvard-educated cardiac surgeon, who just happens to be the Senate Majority Leader. It is still unclear to me whether he endorsed the teaching of ID out of political expediency or a genuine lack of understanding of why ID has not yet risen to the level of science, it's not entirely clear. However, in any case, he succeeded at one of the most difficult surgical specialties there is, cardiac surgery, a specialty steeped in science and a detailed understanding of human physiology and anatomy (mixed, as are all surgical specials, with the art of actually operating), but apparently never developed a sufficient understanding of the scientific method to recognize religion-inspired pseudoscience when he sees it.

Dr. Schwartz is correct that we as physicians, particularly academic physicians responsible for training the next generation of doctors, should do what we can now. What that means for me is two things: First, any students who rotate in my lab get personal instruction from me in the scientific method and how to evaluate clinical trials. Second, when I'm teaching medical students and residents, I try to inculcate in them the concepts and habit of critical thinking. Just the other day, in fact, I spent some time educating the current group of residents and medical students on our service about what confirmation bias is. I was unpleasantly surprised to discover that not one of them had the slightest clue what I was talking about. I can only hope the lesson sinks in.