The Journal of American Physicians and Surgeons: Medical “science” as dubious as it gets

I’m beginning to fear for Kathleen Seidel.

No, I don’t fear for her safety, but I do fear for her sanity. You see, she’s spent way too much time delving into the house organ of the Association of American Physicians and Surgeons (AAPS), namely The Journal of American Physicians and Surgeons (with the unfortunate abbreviation JAPS, which is why they probably insist on using JPANDS), formerly known as Medical Sentinel. I’ve written about JPANDS before, pointing out that its claim of peer review is a sham and that it has an explicitly antivaccine agenda, not to mention its far right wing politics. It only took sampling a few of its articles for me to conclude that JPANDS is useless as a source of valid scientific articles.

But Kathleen dug deeper and found that JPANDS is even worse than I had feared, which is why I hope that she takes a break to let her neurons recover before diving back into the fray again, as the Pooflinger was forced to do to maintain his sanity after delving too deeply into creationist idiocy for too long. In her reading, she’s dug way deeper into JPANDS, reading far more of its articles than even I have dared, even going back to its predecessor Medical Sentinel to find more examples of its flagrant wingnuttery.

It’s not a pretty sight. Kathleen did a pretty comprehensive takedown of AAPS and JPANDS, listing all of their positions and many of the reasons why JPANDS should not be taken seriously as a scientific journal. She also makes the ironic observation that liberal icon RFK, Jr. has used JPANDS as a source for much of his thimerosal conspiracy-mongering. Because Kathleen has done such a thorough job, I’m only going to comment a bit more on three areas of JPANDS: its politics; its stance on vaccinations, and its stance against evidence-based medicine.

Kathleen begins by pointing out that many of the purveyors of the hypothesis that autism is a “misdiagnosis for mercury poisoning” or that autism is due to mercury in childhood vaccines publish in JPANDS, chief among them Mark and David Geier, whose pseudoscience was featured as the lead article in the very first issue of JPANDS in Spring 2003:

Promoters of the hypothesis that autism is a common adverse reaction to vaccination rely heavily upon articles published in the Journal of American Physicians and Surgeons (JPandS, originally Medical Sentinel). Previous perusals of JPandS tables of contents left me with the general impression that its sponsors tended toward the conservative end of the political spectrum. I therefore decided to make a comprehensive survey of the website of the Association of American Physicians and Surgeons, to get a sense of the convictions driving its editorial policies.

Heh. “Tended toward the conservative end of the political spectrum”? That’s an understatement. David Touretsky once said, “I’m a libertarian with a small L. The big-L Libertarians are anarchist loons.” The editorial philosophy of JPANDS reveals it to be a magazine dedicated to big-L Libertarianism in italics and bold. As the AAPS website states:

AAPS members believe this patient-physician relationship must be protected from all forms of third-party intervention. Since its founding in 1943, AAPS has been the only national organization consistently supporting the principles of the free market in medical practice.

It sounds innocuous enough, but why should medicine be “protected from all forms of third-party intervention”? No industry or profession is so protected. One can argue about the level of government oversight that is appropriate in a free nation, but to argue that there should be no oversight or intervention puts far more faith in physicians than even I as a physician have. Indeed, AAPS is explicitly opposed to any form of government regulation of health care; considers the FDA and Health Care Financing Administration to be unconstitutional; is utterly opposed to Medicare; urges physicians not to participate in Medicare; describes public health programs as “tyranny“; and liberally quotes Ayn Rand.

Kathleen aptly describes the philosphy of AAPS as “ultra-conservative-libertarian-individualist — with a generous helping of conspiracism thrown into the mix — reminiscent of the philosophy espoused by the John Birch Society.” However, the Libertarianism of AAPS is not quite without limits. Most Libertarians regard abortion as an individual right that the state should not interfere with except after fetal viability, arguing that a woman should have a near absolute right to control her own body. Not AAPS. It explicitly opposes abortion. Similarly, many Libertarians support open immigration. Not AAPS. It is explicitly for “closing the borders,” and has even published a racist anti-illegal immigrant screed that begins:

Illegal aliens’ stealthy assaults on medicine now must rouse Americans to alert and alarm. Even President Bush describes illegal aliens only as they are seen: strong physical laborers who work hard in undesirable jobs with low wages, who care for their families, and who pursue the American dream.

What is unseen is their free medical care that has degraded and closed some of America’s finest emergency medical facilities, and caused hospital bankruptcies: 84 California hospitals are closing their doors. “Anchor babies” born to illegal aliens instantly qualify as citizens for welfare benefits and have caused enormous rises in Medicaid costs and stipends under Supplemental Security Income and Disability Income.

What is seen is the illegal alien who with strong back may cough, sweat, and bleed, but is assumed healthy even though he and his illegal alien wife and children were never examined for contagious diseases.

By default, we grant health passes to illegal aliens. Yet many illegal aliens harbor fatal diseases that American medicine fought and vanquished long ago, such as drug-resistant tuberculosis, malaria, leprosy, plague, polio, dengue, and Chagas disease.

What is seen is the political statistic that 43 million lives are at risk in America because of lack of medical insurance. What is unseen is that medical insurance does not equal medical care. Uninsured people receive medical care in hospital emergency departments (EDs) under the coercive Emergency Medical Treatment and Active Labor Act of 1985 (EMTALA), which obligates hospitals to treat the uninsured but does not pay for that care. Also unseen is the percentage of the uninsured who are illegal aliens. No one knows how many illegal aliens reside in America. If there are 10 million, they constitute nearly 25 percent of the uninsured. The percentage could be even higher.

It goes downhill from there:

Illegal aliens perpetrate much violent crime, the results of which arrive at EDs. “Dump and run” patients, often requiring tracheotomy or thoracotomy for stab or gunshot wounds, are dropped on the hospital sidewalk or at the ED as the car speeds away.

And:

American hospitals welcome “anchor babies.” Illegal alien women come to the hospital in labor and drop their little anchors, each of whom pulls its illegal alien mother, father, and siblings into permanent residency simply by being born within our borders. Anchor babies are citizens, and instantly qualify for public welfare aid.

I’ve always been in favor of immigration reform that increases the number of legal immigrants permitted and dramatically clamps down on illegal immigration, but the sheer racism apparent in the above passages sickens me. The rest of the article is no better. It portrays illegal immigrants primarily as not-too-bright carriers of disease and crime that are a blight upon our nation and a threat to our health care system. (I almost expected an argument for eugenic measures to follow.) While it is true that unreimbursed care of illegal immigrants is a significant problem in some border states, rhetoric such as in the above article provides much more heat than light on the issue and seems more designed to inflame anti-immigrant sentiments than to suggest solutions to our current predicament.

Now that we’ve established that AAPS and JPANDS are motivated by a far right-wing political orientation, the reader may ask: So what? Although the explicitly political advocacy of AAPS certainly casts doubt on the editorial objectivity of JPANDS, in and of itself that advocacy doesn’t necessarily mean that JPANDS is not a reliable medical journal–that is, unless one looks a little more closely at how that very political orientation influences the choice of publications appearing in JPANDS. One area in which JPANDS departs from the medical mainstream is in its explicit stand against mandatory vaccination and its call for a “moratorium” on vaccine “mandates.” Not surprisingly, JPANDS has been receptive ground for antivaccination articles, including, but not limited to, the Geiers’ publications linking autism with mercury in childhood vaccines. Going back to Medical Sentinel and proceeding to this very day, AAPS has consistently viewed mandatory vaccination as a “tool of the state” and a threat to physician autonomy, while minimizing the contribution of mass vaccination to the elimination of various infectious diseases.

Kathleen lists a number of explicitly antivaccination articles that have appeared in JPANDS over the last three years. Titles range from Is Vaccine Dissent Dangerous? to World Health Organization Vaccine Recommendations: Scientific Flaws or Scientific Misconduct? All have two things in common: First, they do not just question the risk-benefit ratio or complication rates of various vaccines, as “conventional” doctors do all the time; rather the agenda behind these articles is either explicitly or implicitly antivaccine. Second, they are either editorials or “scientific papers” in which the science is consistently of the same poor quality as that found in the Geiers’ most recent article, which I deconstructed last week. Advocates of a link between mercury and autism will no doubt claim that the clear editorial stance of JPANDS does not necessarily invalidate what is published there. True enough. The shoddy science does a good enough job of invalidating it, and JPAND’s editorial stance is merely icing on the cake, not to mention a likely explanation why JPANDS would publish such poorly designed and conducted studies in the first place.

Particularly disturbing is the way in which the authors publishing in JPANDS will use antivaccination rhetoric for truly odious purposes. For example, JPANDS has become a major promoter of the claim that many cases of “shaken baby syndrome” are in actuality due to “vaccine-induced” encephalitis and frequently publishes articles making this argument. Indeed, the most recent issue of JPANDS has three articles devoted either to casting doubt on the concept of shaken baby syndrome or trying to blame many cases on vaccine complications, or both. This is the very defense that Alan Yurko, a man who was convicted of shaking his girlfriend’s ten week old baby son Alan to death in 1999 in Florida, used in his appeals. Strangely enough, he became a hero of the antivaccination movement, which mobilized behind him in a bizarre “Free Yurko” campaign that claimed that baby Alan’s death was due to “vaccine-induced encephalitis,” not Yurko’s violent shaking. As Peter Bowditch describes it:

Murderer Alan Yurko is to serve only 2317 days in prison for beating his girlfriend’s baby to death, after Circuit Court Judge C. Alan Lawson ruled that problems with the baby’s autopsy report justified a new trial. The autopsy report seems to be an extremely sloppy document, prepared by a medical examiner with a history of carelessness, and the judge correctly ruled that the jury in Yurko’s original trial might have come to a different conclusion if the autopsy evidence had been presented differently. (In an interesting example of doublethink, Yurko’s lawyers claimed at one point in the hearing that the examiner had mixed up the parts of two bodies which were being autopsied at the same time, and at another point stated that there were no other autopsies carried out for a week either side of the one for Yurko’s victim. That must have been one very messy and untidy morgue.) Despite what Yurko’s supporters are claiming, the judge did not declare him “innocent”, and the quashing of the conviction did not support the insane idea that vaccination had anything to do with the baby’s death. In fact, the judge quite explicitly rejected the testimony from the usual collection of demented anti-vaccination doctors who appeared before him to tell him why Yurko could not possibly have hurt the child.

Prominent among Yurko’s defenders was Dr. Harold Buttram, who–surprise, surprise!–published an argument for this very concept of shaken baby syndrome as being due to vaccine injury in Medical Sentinel back in 2001 and in JPANDS in 2004. Also prominent among Yurko’s defenders was veterinarian toxicologist Dr. Mohammed Al-Bayati, who, although not a pathologist, wrote a dubious “report” in which he purported to demonstrate that baby Alan’s cerebral hemorrhages were not due to violent shaking but rather to a combination of antibiotics and vaccination injury. Sound familiar? It should. We’ve met Dr. Al-Bayati before, when he performed a similar service for Christine Maggiore, the HIV-positive AIDS “dissident” who does not believe that HIV causes AIDS, a belief that likely contributed to the death of her daughter from AIDS-related complications. Dr. Al-Bayati’s “report” blamed Eliza Jane’s death primarily on an allergic reaction to amoxicillin and a parvovirus infection, rather than on Pneumocystis cariini pneumonia and HIV encephalitis, which is what the L.A. County Coroner had identified as the cause of death. The Al-Bayati “report” has been thoroughly debunked by me and others as an example of bad medicine and bad science based on speculation without a foundation in the autopsy findings or in what is known about parvovirus and allergic reactions to amoxicillin. Naturally, this report is being held up by HIV/AIDS “dissidents” as “proof” that EJ did not die of AIDS, as his earlier, equally dubious, report is represented by antivaccination activists as “proof” that vaccines are responsible for many cases of shaken baby syndrome.

Is there a common thread here, besides an extreme political orientation and a willingness to ignore evidence that doesn’t conform to the preconceived beliefs espoused by AAPS? I believe there is and that Kathleen found it when she quoted this article by Editor-In-Chief of JPANDS and former President of AAPS Lawrence Huntoon:

Inescapably, the herd is a force to be reckoned with in all of our professional lives. We must be prepared to travel with it or alongside it, to one degree or another, without being trampled or singled out for extermination. And, for those few physicians who still believe in individual-based medicine practiced according to the principles of Hippocrates, and in watching out for one another when one of our own is attacked, fortunately we have the AAPS. We are a fellowship of “different doctors,” and the distinction is apparent.

“Singled out for extermination” as a maverick? That’s a bit overblown, but that’s the attitude at AAPS. “Different doctors”? Well, it’s hard to argue with that, but it is unclear whether “different” means “better.” What is clear is that the AAPS values “maverick” status and total physician autonomy almost above all else. There’s not necessarily anything inherently wrong with prizing “maverick” status or bucking the status quo, at least to a point. That’s one way in which science advances. (The incremental building upon what has gone before is, however, actually the predominant manner of scientific progress.) Mavericks buck the status quo, and do sometimes lead to the overthrow of existing paradigms and the acquisition of new scientific knowledge. One commonly cited example is that of Robin Warren and Barry Marshall, the discoverers that Helicobacter pylori is the cause of most duodenal ulcers. Here’s the rub, though: Mavericks follow the wrong path far more frequently than they follow the right path. As Michael Shermer has said, “Heresy does not equal correctness,” and continued in his book Why People Believe Weird Things:

For every Galileo shown the instruments of torture for advocating scientific truth, there are a thousand (or ten thousand) unknowns whose ‘truths’ never pass scientific muster with other scientists.

Indeed.

As I wrote a long time ago in a blog far, far away in a post entitled The Galileo Gambit:

For every Galileo, Ignaz Semmelweis, Nicolaus Copernicus, Charles Darwin, Louis Pasteur, etc., whose scientific ideas were either ignored, rejected, or vigorously attacked by the scientific community of his time and then later accepted, there are untold numbers of others whose ideas were either ignored or rejected initially and then were never accepted–and never will be accepted. Why? Because they were wrong! The reason the ideas of Galileo, Semmelweis, Copernicus, Darwin, Pasteur, et al, were ultimately accepted as correct by the scientific community is because they turned out to be correct! Their observations and ideas stood up to repeated observation and scientific experimentation by many scientists in many places over many years. The weight of data supporting their ideas was so overwhelming that eventually even the biggest skeptics could no longer stand. That’s the way science works. It may be messy, and it may take longer, occasionally even decades or even longer, than we in the business might like to admit, but eventually in science the truth wins out. In fact, the best way for a scientist to become famous and successful in his or her field is to come up with evidence that strongly challenges established theories and concepts and then weave that evidence into a new theory. Albert Einstein didn’t end up in the history books by simply reconfirming and recapitulating Newton’s Laws. Semmelweis and Pasteur didn’t wind up in the history books by confirming the concept that disease was caused by an “imbalance of humours” (although Semmelweis probably did hurt himself by refusing to publish his results for many years; his data was so compelling it remains puzzling why he did not do so). I daresay that none of the Nobel Prize winners won that prestigious award by demonstrating something that the scientific establishment already believed. No! They won it by discovering something new and important!

It’s also hard not to point out the arrogant tone of Dr. Huntoon’s article. To him, the AAPS is devoted to “different doctors” who don’t meekly follow evidence-based guidelines, as the rest of what he views to be the “herd” does or adhere to nitpicky little things like the careful science that leads to those guidelines. No! These doctors are different and, by inference, better, more capable of independent thought than the rest of us poor, pathetic “sheep.”

How Ayn Randian of him!

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! No wonder JPANDS has published several articles with titles such as Evidence-based Guidelines: Not Recommended, The Effect of Peer Review on Progress: Looking Back on 50 Years in Science (featuring another scornful dismissal of the “herd instinct” and “conformity” and a fair amount of exaggeration of how much scientific progress is due to “violent confrontation” of old paradigms and how much is due to the slow accumulation of knowledge), and editorials attacking evidence-based medicine. To AAPS, evidence-based guidelines appear to be unacceptable limits on the autonomy of doctors, as are any government regulations or third party payer systems.

Does any of this also sound familiar? Cranks and pseudoscientists often have the same attitude, along the lines of: “Damn those pesky ‘conventional’ scientists, with their insistence on careful observation, hypothesis generation, and experimentation! They don’t have the insight to see that I am right!” Although many of the authors publishing in JPANDS are probably not cranks, it’s clear to me that the AAPS appears to be an organization custom-made to attract cranks, regardless of their political orientation. Even those opposed to the far right wing core beliefs of AAPS could well be attracted by its promise of restoring a golden time when the authority and autonomy of physicians was not questioned and its attitude that there should be no outside constraints on the practice of medicine by physicians, whether those constraints come from the government or from evidence-based medicine. Those who view themselves as “mavericks” in their fields might also be so attracted, even if they don’t buy all the political baggage that comes with AAPS.

This attitude towards evidence is in conflict with true science. The true scientist always doubts, always wonders if he is correct. The true scientist is always testing his hypotheses against the data and wondering if there was something he might have missed. It involves careful experimentation and interpretation of the results of those experiments in a cautious light, with knowledge of what science has found before. Yes, sometimes there’s a bolt out of the blue and an existing paradigm must be overthrown, but more often science builds on what has gone before.

No wonder JPANDS is not indexed in MEDLINE, and no wonder so much quackery somehow manages to appear there first. If I were a quack, it’s one of the first places I’d send my papers–as a “maverick,” of course.

ADDENDUM: Joseph over at Autism-Natural Variation has had a rather interesting e-mail exchange with Dr. Huntoon, the Editor-In-Chief of JPANDS:

Open Letter to Journal of Physicians and Surgeons
JAPANDS Dismisses Retraction Request – Offers to Publish Letter to Editor Instead

No surprise that Dr. Huntoon doesn’t see the problem brought up in Joseph’s letter.