I’m always hesitant to write about matters that are more political than scientific or medical, although sometimes the sorts of topics that I blog about inevitably require it (e.g., the 21st Century Cures Act, which never died and a retooled version of which is still being considered). This is one of those times. Yesterday, I woke up to the news that President-Elect Donald Trump had chosen Rep. Tom Price (R-GA) as his new Secretary of Health and Human Services. The Department of Health and Human Services (DHHS), of course, figures fairly prominently in a couple of frequent topics on this blog because major federal agencies that I write about are within the DHHS, including the CDC (vaccine issues), the FDA (drug approval and drug safety), and, of course, the National Institutes of Health (NIH). So the HHS Secretary matters, at least for purposes of discussing Science-Based Medicine. Then there’s also the issue of Donald Trump’s long history of rabid antivaccine views, coupled with the other issue of his having met secretly with Andrew Wakefield in August in Florida and, after the election, antivaccine activists seeking to influence him based on that meeting. I was looking for a signal in whomever Trump picked regarding whether he would actually do anything about vaccine policy potentially harmful to public health. Heck, as I’ve noted before, Vice President Mike Pence apparently doesn’t believe that smoking causes cancer and premature death.
So why did Tom Price catch my attention more than other Trump cabinet picks? Yes, he detests Obamacare and is likely to be fully enthusiastic about gutting it, but pretty much anyone Trump picked would have been expected to hold that view. It’s pretty much par for the course for the Republican Party these days. I would have been more surprised if whomever Trump picked was relatively neutral on Obamacare. No, what caught my eye was that I learned that Tom Price is a member of the Association of American Physicians and Surgeons (AAPS), and that told me a lot about him, none of it good. For instance, in 2015 Charles Pierce referred to Price as “one of Georgia’s wingnut sawbones” (Price is an orthopedic surgeon), and noted an article by Stephanie Mencimer, The Tea Party’s Favorite Doctors, which included this description of the AAPS:
Yet despite the lab coats and the official-sounding name, the docs of the AAPS are hardly part of mainstream medical society. Think Glenn Beck with an MD. The group (which did not return calls for comment for this story) has been around since 1943. Some of its former leaders were John Birchers, and its political philosophy comes straight out of Ayn Rand. Its general counsel is Andrew Schlafly, son of the legendary conservative activist Phyllis. The AAPS statement of principles declares that it is “evil” and “immoral” for physicians to participate in Medicare and Medicaid, and its journal is a repository for quackery. Its website features claims that tobacco taxes harm public health and electronic medical records are a form of “data control” like that employed by the East German secret police. An article on the AAPS website speculated that Barack Obama may have won the presidency by hypnotizing voters, especially cohorts known to be susceptible to “neurolinguistic programming”—that is, according to the writer, young people, educated people, and possibly Jews.
I realize that just because Tom Price is a member of the AAPS doesn’t necessarily mean that he subscribes to all its views—or even most of them. Maybe he’s like the Trump voters who were attracted by other things about him or hated Hillary Clinton more than they were disturbed by his racism, embrace of
the alt right white supremacist movement, misogyny, and conspiracy mongering. Maybe Price was attracted by the AAPS view that rejects nearly all restrictions on physicians’ practice of medicine, purportedly for the good of the patient, its support of private practice and dislike of government regulation of medicine to the point that he ignored its promotion of dangerous medical quackery, such as antivaccine pseudoscience blaming vaccines for autism, including a view that is extreme even among antivaccine activists, namely that the “shaken baby syndrome” is a “misdiagnosis” for vaccine injury; its HIV/AIDS denialism; its blaming immigrants for crime and disease; its promotion of the pseudoscience claiming that abortion causes breast cancer using some of the most execrable “science” ever; its rejection of evidence-based guidelines as an unacceptable affront on the godlike autonomy of physicians; or the way the AAPS rejects even the concept of a scientific consensus about anything. Let’s just put it this way. The AAPS has featured publications by antivaccine mercury militia “scientists” Mark and David Geier. Even so, the very fact that Price was attracted enough to this organization and liked it enough to actually join it should raise a number of red flags. It certainly did with me, because I know the AAPS all too well.
I haven’t written much about the AAPS, but the first time I ever encountered the group was over a decade ago. Given that Tom Price is now in the news as Trump’s selection for DHHS, now appears to be a good time to revisit the AAPS, although I have already briefly done so because, not surprisingly, the AAPS has been a huge foe of Obamacare. Consistent with the conspiratorial bent of many AAPS leaders, AAPS CEO Dr. Jane Orient peddled medical conspiracy theories that Hillary Clinton was “medically unfit to serve.”
Since it’s been a long time, I decided to peruse the most recent episodes of the Journal of American Physicians and Surgeons (JPANDS), to see what the group has been up to, “scientifically” speaking. Not surprisingly, the Fall 2016 issue contained the usual rants against Medicare and taxes and complaints about the “end of fee-for-service medicine” (perhaps the “threat” that animates the AAPS perhaps more than anything else), but it also contained other typical AAPS bugaboos. For instance, there is this article decrying mandatory influenza vaccination for health care professionals, in which a fictional nurse named Rebecca is demonized by her coworkers for refusing the flu vaccine, along with some familiar anti-flu vaccine tropes.
Then, consistent with the hostility of the AAPS towards evidence-based medicine, there is this “gem” of an article, The Evidence-Based Transformation of American Medicine by Hermann W. Børg, MD. Let’s just say that Dr. Børg writes about evidence-based medicine as though it were a bad thing. If there’s another thing (besides Medicare or any hint of federal “control” of medicine) that the AAPS hates with a passion, it’s evidence-based medicine. It’s an article that combines the reasonable, such as questions about pharmaceutical influence in generating EBM guidelines and the contention that for preventative interventions we should pay attention to the number needed to treat and to absolute risk reductions more than relative risk reduction, and real howlers, like this paean to anecdotal evidence:
The very low level of quality assigned to anecdotal evidence in this system requires a brief comment. In keeping with the mantra that “the plural of anecdote is not evidence,” any usefulness of “anecdotes” in clinical practice is dismissed outright by EBM. However, as one wise professor observed, “Every epidemic starts with a single case report” (R.L. Kimber, personal communication, 2000). Serendipitous breakthroughs are made by individuals who make careful observations of patients from close range, seldom or never by a team encumbered by a rigid experimental protocol and the huge number of subjects needed to reach statistical signicance. Single observations may be extremely important, even if not statistically significant in the context of a large trial. Say, for example, a rare, otherwise unexplained event follows a medical intervention: a patient takes a drug and inexplicably goes blind. It might be a coincidence, or it might be a side effect of the drug. One cannot rule out a causal relationship based on lack of a statistically significant difference in this occurrence between the drug and placebo groups in a trial of insufficient power to detect a rare event. One is obligated to investigate further.
This is, of course, a straw man so massive that, were it real, the astronauts living on the International Space Station could see it from orbit. EBM (and science-based medicine) recognize the importance of anecdotes, but as hypothesis-generating observations, not hypothesis-confirming observations. Moreover, serious adverse events, such as blindness, are not dismissed as “correlation not equaling causation” without investigation. Certainly the FDA would not dismiss multiple reports of blindness after a drug dose as “the plural of anecdotes not being data.” While I will concede that sometimes skeptics use that quip about anecdotes a bit too freely, but in actual practice clinical observations of a reaction as serious as the example given by Dr. Børg are not dismissed as coincidence without investigation, consistent with the role of anecdotes as hypothesis-generating. Basically, Dr. Børg, again consistent with the AAPS view of the physician as supreme, wants the freedom to be able to use clinical observation in any way he wants without restriction by those pesky EBM guidelines and to interpret medical evidence any way he wants, even if it conflicts with how the vast majority of the field interprets it.
If you want a distillation of how the AAPS views EBM guidelines, Dr. Børg gives it:
Strict application of EBM implies a mechanistic algorithm- driven approach, similar to primitive pre-artificial-intelligence computer programs of the past. In such an approach, the doctor sees the patient as a statistic rather than an individual. This sort of medicine could be practiced by administrators. In the real world, however, clinical trials may tell which treatments are e ective, but not necessarily which patients should receive them.
Modern studies of the human genome and proteome have deepened our understanding of the importance and vast extent of biochemical individuality. The patient could be in a subset of patients whose excellent response to an intervention was diluted out in the large number of randomized subjects. It is recognized, for example, that two genes affect how patients process 25 percent of drugs now on the market. In fact, advances in pharmacogenetics may render the EBM model obsolete and replace it with “Genomic Medicine.” One of the major promises of pharmacogenomics is the ability to precisely predict the individual patient’s response to medical intervention, without the need to indirectly draw such conclusion from the large epidemiology-based studies.
Bloody hell. This is exactly the same sort of rationale that functional medicine quacks use to justify in essence, doing anything they believe in to treat patients, all in the name of respecting the patient’s “biochemical individuality” and as an excuse to make it up as one goes along. (Heck, he even uses the same term!) As I like to point out, there is already room in EBM guidelines for the physician’s clinical judgment. However, if a physician deviates from EBM guidelines significantly, it is expected that he or she should have a damned good reason for doing so.
Also, where nowhere near this precision medicine utopia yet, mainly because we lack understanding of the significance of various mutations and differences in gene expression when measured on a whole genome basis. Clinical trials are still necessary. They are also evolving in order to incorporate genomic data and biomarkers in treating patients. One form these new trials take is the so-called “adaptive trial,” which uses patient outcomes and biomarkers to immediately inform further treatment decisions. So, though, results from these trials have been disappointing. Again, Dr. Børg seems to be invoking genomics more as an excuse to dismiss EBM guidelines than anything else.
Now, one might say that Price might not know anything about articles like this, and that’s certainly possible. On the other hand, the reason I cited Dr. Børg is because his article represents what is perhaps the overarching view that is the cornerstone of the AAPS: The fetishization above all else of the individual doctor’s judgment and hostility to any restriction on physician autonomy, or, as I like to characterize it, anything that smacks of “telling doctors what to do.” Truly AAPS worships “brave maverick doctors” and castigates doctors following EBM as going with the herd. Basically, as I described the first time I discussed the AAPS, the leadership of the AAPS and apparently many who publish in JPANDS seem to be a bit too enamored of their self-proclaimed “maverick” status and give the appearance of thinking that, like Ayn Rand’s hero, they’re “supermen” whose egoism and genius will inevitably prevail over timid traditionalism and social conformism. Reigning them in with evidence only interferes with their autonomy and prevents them from exercising their genius for the good of their patients. If only the “herd” could appreciate that!
Oh, and as recently as the Summer 2016 issue of JPANDS, the AAPS was still publishing risible antivaccine pseudoscience in the form of an article by Neil Z. Miller entitled Combining Childhood Vaccines at One Visit Is Not Safe. Let’s just say that it lived down to the usual very low scientific standards of JPANDS, as I described in detail in June.
Tom Price probably doesn’t buy into all the quackery and Ayn Rand-worshiping wingnuttery of the AAPS, and, although I do believe he’s a very bad choice for DHHS, fortunately thus far I have found no evidence that he is antivaccine and have even heard that antivaccinationists are not happy with this choice for DHHS. I do know that the One Crank To Rule Them All, über-quack Mike Adams, is practically twisting himself into a pretzel justifying a “wait and see” attitude even though he is clearly very upset over this choice because Price voted against GMO labeling. (No, I’m not going to link to him.) However, you can learn a lot about a person by the people with whom he associates and the groups he joins and supports. By joining the AAPS, Price has shown that he is clearly attracted to a pre-Medicare vision of a golden era of absolute physician autonomy with minimal or no government interference or programs like Medicare, as well as a hostility towards evidence that conflicts with that vision. There is no arguing this, as these are beliefs that are baked into the DNA of the AAPS; they are central to the organization. Attraction to such beliefs is not a good trait for a Secretary of HHS to be attracted to, and I haven’t even really gotten into Price’s fundamentalist antiabortion beliefs, and his implacable opposition to gun control. It’s going to be a long four years when it comes to health policy.