Just because medical consensus evolves does not justify your quackery

If there’s one thing that I came to understand over my two-plus decades of critically evaluating the claims of “brave maverick doctors,” the vast majority of whom are really just quacks, it’s that quacks hate the very concept of scientific and medical consensus. Indeed, long ago I pointed out that hostility towards the very concept of scientific consensus is a red flag, a very good indicator that the person expressing such hostility is a science denier (or quack, if it’s a physician). Moreover, although I concede that anyone has the “right” to “challenge” a scientific consensus, the bigger problem in the age of social media is recognizing when someone doing the challenging has the necessary expertise to make a scientifically robust challenge, compared to the vast majority of such “challenges,” which are made by pseudoexperts in different fields who think they have the necessary expertise but do not or by lay people who don’t even have the basic expertise necessary. Unsurprisingly, we have seen this phenomenon play out in a world stage since COVID-19 was first declared a pandemic three and a half years ago. However, even though seeing pseudoexperts about COVID-19 and mRNA vaccines flourish during the pandemic did not surprise me, I will admit, though, that even I was somewhat surprised at the sheer scale and influence of the phenomenon and how much it bled into mainstream politics and culture this time.

As I was thinking about this last week, I remembered a Substack post that I had encountered recently that reminded me of a common technique of pseudoexperts and quacks challenging scientific and medical consensuses, namely to conflate their misinformation with “innovation” and the normal evolution of scientific and medical consensuses. The post appeared—because of  course it did—on the Frontline COVID-19 Critical Care (FLCCC) Alliance Substack a couple of weeks ago and is entitled 25 Times Medical Consensus Had To Be Rethought, with its blurb giving the game away:

These examples are a reminder of the need for ongoing research, humility, and the willingness to challenge established beliefs for the sake of patient care.

Far be it from me to argue against “ongoing research, humility, and the willingness to change established beliefs for the sake of patient care,” but you can see the game right away: to deceptively conflate the quackery promoted by FLCCC doctors with normal medical innovation, while equating critics of the FLCCC and its quackery with the doctors who, for example, refused to believe the 19th century findings of Ignaz Semmelweis, who linked lack of handwashing by obstetricians with puerperal fever that killed newborns and attacked him for his findings. (Hint: FLCCC is not Semmelweis.) Remember, FLCCC is a conspiracy-mongering bunch of grifting quacks promoting disproven “repurposed” treatments for COVID-19, such as ivermectin, hydroxychloroquine, and the grab bag of supplements and other repurposed drugs in their “early treatment protocols.” Indeed, two of FLCCC’s founders, Dr. Pierre Kory and Dr. Paul Marik recently reported that the American Board of Internal Medicine (ABIM) had informed them that its Credentials and Certification Committee had recommended rescinding their board certifications, portraying the ABIM’s action as “persecution” by a corrupt organization.

Clearly, this Substack post on medical consensuses is part of the FLCCC’s campaign in response to the ABIM decision to portray its founders not as the quacks they are but rather as “brave maverick doctors” successfully challenging the medical consensus on COVID-19 and COVID-19 vaccines. Unsurprisingly, the FLCCC spins a conspiratorial narrative that portrays quacks (like its very own Drs. Kory and Marik) as “innovators” and the scientific consensus as corrupt and riddled with conflicts of interest, often controlled by whatever “enemy” dominates the conspiracy theory; in the case of COVID-19 and antivax narratives, it’s usually—but not always—big pharma.

The false narrative equating FLCCC quackery to challenges to the scientific consensus

Right from the very beginning the Substack entry by FLCCC, the anonymous authors make it very clear what the FLCCC is about by proclaiming:

There’s been much debate lately about the value of medical consensus.

“What matters is consensus!” astrophysicist Neil deGrasse Tyson excitedly told Del Bigtree, on a recent episode of The Highwire. He seemed to be arguing that medical or scientific “consensus” is more important than the knowledge and experience of individual scientists.

Medical certification and licensing boards also claim that individual healthcare providers who share information that is contrary to “consensus-driven scientific evidence” are misinformation spreaders who cause so much potential harm that their certifications or licenses should be revoked.

I discussed that episode of The Highwire myself not long after it was posted, pointing out that it was a huge mistake on Neil deGrasse Tyson’s part to agree to “debate” Del Bigtree. On the show Bigtree did his best to portray the scientific consensus about COVID-19 as not just wrong but disastrously wrong and existing solely to shut down “dissent,” while proclaiming how the cranks will someday be vindicated by overcoming the “consensus. However, as large a mistake as I thought it was for deGrasse Tyson to appear on Bigtree’s quackfest of a podcast, one thing that I thought deGrasse Tyson got right was his discussion of what a scientific consensus is and why it’s important, regardless of how much Bigtree tried to twist the narrative. (Unsurprisingly, Dr. Paul Marik was one of the “brave maverick” doctors listed as bucking the “consensus.”

Antivaxxers tried to cherry pick a single quote from Bigtree—”the individual scientist doesn’t matter”—that, taken out of context, can be misinterpreted as dismissing scientists who report findings that question the current scientific consensus. In fact, NDT spent considerable time explaining how and when an individual scientist does and doesn’t matter with respect to scientific consensus, in particular how hard it is to tell when an individual scientist’s finding that calls consensus into question is just an outlier or when it might be the first indication of an “emerging truth.” Personally, whenever cranks like the FLCCC question scientific consensus as a concept, I point out that a scientific theory is nothing more than the best existing scientific consensus concerning a particular area or question in science; e.g., the Theory of Relativity, the Theory of Evolution, etc. Back in the days when I used to write about evolution a lot, this explanation used to serve as a two-fer, too, because it effectively defangs the dismissal of evolution as “just a theory.” As I also like to point out, how you question a scientific consensus matters at least as much as the specific questioning. “Questions” about the scientific consensus from groups like FLCCC are often based on misrepresentations of what the consensus actually is, bolstered by cherry picked science, conspiracy theories, and poor reasoning.

As for the ABIM recommending revoking the medical license of two of FLCCC’s biggest quacks, Drs. Paul Marik and Pierre Kory, I wrote my detailed take three weeks ago. TL;DR version: It is appropriate for a certifying board like the ABIM to revoke the board certifications of doctors like these, but they should do it not just for spreading dangerous medical misinformation during a pandemic (the stated reason) but for practicing quackery, which I argue that Drs. Kory and Marik do, particularly given that spreading medical misinformation nearly always goes hand-in-hand with practicing actual quackery.

The FLCCC then predictably moves on to a common quack argument:

While some might argue in favor of the merits of consensus in providing timely guidance, it is important to correct for the many potential biases, beliefs, preferences, and conflicts of interest that could lead to subjective consensus decisions, and to ensure that consensus-based recommendations reflect the views of a heterogenous and diverse group of experts.

How can it be a consensus when all sides of an issue have not been considered and differing views are being censored? What about all the out-of-the-box thinkers in history who have challenged conventional thinking and moved the needle forward for all humankind?

Consensus is, in fact, a perfect cover for conflicts of interest like ties to pharmaceutical companies, medical device manufacturers, or other commercial entities, which compromise the integrity and impartiality of the consensus process. Or, some experts may be more inclined to favor consensus recommendations aligned with the interests of their research funding sources. Others may have intellectual biases based on long-standing beliefs or theories they are hesitant to challenge.

Perhaps, but that doesn’t justify pseudoscience and quackery. Again, quacks love to cite problems and shortcomings in how scientific consensus develop and evolve in order to give the appearance that these deficiencies imply that their quackery is a valid “challenge” to the consensus. Not that that stops FLCCC from doubling down:

And what about all the times in medical history when consensus beliefs were proven wrong, and patients were harmed in the process because the establishment clung to a flawed premise?

Once a consensus is reached, there is often resistance to updating recommendations based on new and emerging evidence, which leads to guidelines becoming quickly outdated and not reflecting the latest advances in science. Studies have shown that even after claims have been disproven in the medical literature, they often persist for years and even decades before they retreat from use.

Dr. David Sackett, considered one of the ‘fathers’ of evidence-based medicine, once had this advice for medical students:

“Half of what you’ll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half – so the most important thing to learn is how to learn on your own.”

I’ve heard this quote before, and, quite frankly, have always thought it to be a gross exaggeration. Medical science does evolve, but not quite that rapidly. I like to cite my own specialty, breast cancer surgery, to point out that, yes, the surgical treatment of breast cancer is very different than it was when I graduated from medical school over three decades ago, but it actually took decades for those changes to manifest themselves. For example, five years after I graduated from medical school, the treatment was basically the same. Ten years on, for the evaluation of whether breast cancer had spread to the axillary lymph nodes under the arm or not, the use of sentinel lymph node biopsy (a technique that involves removing only one or a few targeted lymph nodes under the arm) instead of axillary dissection (in which all the lymph nodes under the arm are removed) was being tested clinical trials. By 15 years after graduation, the sentinel lymph node biopsy had largely replaced axillary dissection for axillary staging, although it wasn’t until well over 20 years after I had graduated from medical school that the NSABP-32 randomized controlled clinical trial was finally published and nailed down definitively the equivalence between the two techniques in terms of outcomes. In other words, medical practices most definitely do evolve in response to evidence, but most medicine doesn’t change nearly as quickly as Sackett claimed.

That’s not to say that change doesn’t sometimes happen rapidly. One example is chemotherapy for a type of breast cancer called “triple negative” (lacking estrogen and progesterone receptors and not expressing an oncogene called HER2), which had remained largely the same for decades. As a result of the reporting of the KEYNOTE-522 RCT in 2020, the standard of care changed very quickly to incorporate immunotherapy with chemotherapy, and now pretty much all patients with triple negative breast cancer receive immunotherapy as well as a variation of old chemotherapy regimens, with greatly improved results. (No doubt conspiracy theorists will blame big pharma, given that Merck Sharp & Dohme funded the study.)

The point is that it’s way more complicated than Sackett’s all too easy adage makes it seem. Some medical practices evolve slowly or even not at all. (After all, if a treatment works and no one has found anything better yet, why change?) Others evolve slowly, while a few change rapidly in response to evidence like the KEYNOTE-522 trial. Quacks love to imply that the rapid evolution of some medical practices is how all medicine evolves, all while portraying their quackery as being on the “cutting edge” that hidebound doctors, resist because they are blinded by habit and comfort with current consensus, as well as—of course!—conflicts of interest (i.e., they are pharma shills), and that is exactly what FLCCC is doing here.

The post concludes with a list of 25 times the “medical consensus had to be revisited,” repeating again that the list is a “reminder of the need for ongoing research, humility, and the willingness to challenge established beliefs in the pursuit of patient-centered healthcare.” I respond again that no one—I mean, no one—opposes the “need for ongoing research, humility, and the willingness to challenge established beliefs in the pursuit of patient-centered healthcare,” with perhaps the exception of arrogant quacks like Dr. Kory who proclaim themselves humble but then have the unfettered arrogance to think that they have come up with a highly effective treatment for a disease that no one else could develop or demonstrate to be effective. In fact, what we supporters of SBM oppose is quackery being misrepresented as “innovation.” As for the 25 times the consensus “changed,” the list represents a combination of legitimate examples described more or less correctly, legitimate examples described in a highly biased and misleading way, and dubious examples. Some of the legitimate, rather blandly described, examples include changes in cancer screening guidelines (e.g., PSA testing and mammography), changes in the definition of the blood pressure levels that constitute hypertension, high dose chemotherapy and bone marrow transplantation for breast cancer, the use of aspirin for primary prevention of cardiovascular disease, and routine opioid use for chronic pain. Neglected by Dr. Kory is the historical fact that the vast majority of these changes in medical consensus were driven not by “brave maverick” doctors like him, but by the slow, iterative accumulation of evidence from basic science and/or clinical observations and trials.

Some of the examples in the list are clearly meant to “poison the well” by equating distortions of medical history frequently cited by quacks as being the same as legitimate changes in the medical consensus.

One particularly dubious example is #5 (“Smoking and health risks”):

For much of the 20th century, the tobacco industry worked tirelessly to cast doubt on the harmful effects of smoking, while medical professionals were slow to recognize the dangers. Smoking was initially endorsed and even advertised as a harmless or health-enhancing habit. It wasn’t until landmark studies, such as the 1964 Surgeon General’s Report, that smoking was unequivocally linked to lung cancer, heart disease, and a myriad of other health issues. The battle against tobacco use highlighted the dangers of delaying action due to industry influence and the importance of evidence-based decision-making in public health.

It is true that the tobacco industry did indeed “work tirelessly to cast doubt on the harmful effects of smoking,” but, as most cranks do, FLCCC conflates advertising that used models or actors playing doctors who endorsed smoking as, at minimum, harmless or even beneficial with the actual medical consensus. In reality, by the 1930s, medical science was noticing the harmful effects of smoking, and the scientific findings linking smoking to lung cancer predated the 1964 Surgeon General’s report by at least two decades. As documented in Robert Proctor’s book The Nazi War on Cancer (a book I highly recommend), in fact Nazi scientists had found evidence strongly linking smoking to lung cancer by the early 1940s, a finding confirmed in the early 1950s in studies by Sir Richard Doll and Sir Austin Bradford Hill showing a massively increased risk of lung cancer associated with smoking, to be followed by studies linking smoking to bladder and other cancers as well as cardiovascular disease. Indeed, the Surgeon General’s report in 1964 was a decade behind the science, which is one thing that could be criticized.

While I agree with the observation that the tobacco industry’s decades-long campaign against emerging scientific findings that increasingly found severely detrimental health effects attributable to tobacco use “highlighted the dangers of delaying action due to industry influence and the importance of evidence-based decision-making in public health,” I also point out that what the FLCCC is doing is more akin to what the tobacco company did than what Doll, Bradford Hill, and the Surgeon general did: Promote misinformation, bad science, and pseudoscience to cast doubt on scientific findings. In other words, FLCCC and its allied brave maverick doctors are not the heroes in this comparison.

Another questionable example is #1, thalidomide:

In the late 1950s and early 1960s, thalidomide, a sedative, and anti-nausea medication, was widely prescribed to pregnant women to alleviate morning sickness. Regrettably, it was believed to be safe for use during pregnancy, even though some animal studies indicated potential risks. Tragically, thousands of babies were born with severe limb deformities, known as phocomelia, because their mothers took thalidomide during pregnancy. This devastating outcome exposed the flaws in the medical consensus of the time and led to the establishment of stricter drug safety regulations.

There was never an actual medical “consensus” in the late 1950s and early 1960s about thalidomide. If anything, thalidomide is another cautionary tale about the dangers of marketing and physicians jumping on a medical bandwagon before there was adequate evidence. Indeed, while thalidomide was approved for use in Europe, it was never approved in the US at this time, largely thanks to the FDA doing its job by raising concerns about safety signals in the studies submitted by the manufacturer in its application for funding raised by the FDA scientist, Dr. Frances Oldham Kelsey, reviewing the application for FDA approval. She (and the FDA) held firm in spite of huge pressure brought to bear on them over the course of a couple of years by the drug’s manufacturer William S. Merrell Company of Cincinnati, which had applied to market thalidomide under the trade name Kevadon. For having “prevented a major tragedy of birth deformities” (which she undoubtedly had), Dr. Kelsey was awarded the Distinguished Civilian Service Medal, the nation’s highest federal civilian service award, by President John F. Kennedy in 1962. It was an award that she richly deserved. Indeed, she didn’t retire until 2005, and in 2010 she was the first recipient of an FDA award named after her and continues to be awarded annually. When she finally passed away in 2015 at the ripe old age of 101, the tributes rolled in for her role in standing up for drug safety and preventing the thalidomide catastrophe from spreading from Europe to the US.

As a result of the thalidomide scandal, Congress passed the Kefauver-Harris Drug Amendments to the Federal Food, Drug, and Cosmetic Act. These amendments required that drug companies not just show safety, as had been the case prior to the amendments, before their drugs could be FDA-approved, but also to provide substantial evidence of effectiveness for the product’s intended use. That evidence had to be in the form of adequate and well-controlled clinical trials, which at the time was considered a revolutionary requirement. (Believe it or not, no requirement for high quality clinical trials as a condition of drug approval existed before 1962.) This led to the current system of phase I, II, III, and IV clinical trials in force today. The amendments also included a requirement for informed consent of study subjects and codified good manufacturing processes, as well as the requirement that adverse events be reported. This has been, with some tweaking over the years, the law of the land regarding how the FDA approves drugs for specific indications. Again, the thalidomide scandal is far more of an example of the bad things that can happen when doctors and various regulatory agencies let actors promoting persuade doctors to start using inadequately tested treatments.

Lest you fail to get the message, there’s also #7 on the FLCCC list, bloodletting:

Bloodletting, the practice of deliberately withdrawing blood from a patient, was a widely accepted medical treatment for various illnesses in ancient times and throughout the Middle Ages. It was believed to restore the balance of bodily humors. However, with advancements in medical knowledge, the practice was eventually recognized as ineffective and potentially harmful, leading to its abandonment.

Got it? The medical consensus is just like bloodletting, a practice rooted in prescientific vitalism that persisted for millennia until the rise of scientific medicine in the 19th century finally all too slowly eradicated it. It’s hard not to note parallels between what the FLCCC advocates and bloodletting, namely the use of the personal anecdotal experience of physicians as all the evidence necessary to justify the use of a treatment, even though science shows how misleading personal anecdotal experience can be, given human cognitive tendencies such as confirmation bias and selective memory, as well as how regression to the mean can make an ineffective treatments like reiki and homeopathy appear effective.

I swear, I’m rather surprised that the FLCCC had the restraint not to include Ignaz Semmelweis’ observations and the reaction of the 19th century European medical establishment to them on its list. As I mentioned above, that is among the favorite examples cited by quacks.

“Brave mavericks” vs. the scientific consensus

Quacks like the FLCCC love to represent the medical consensus about the diagnosis and treatment of whatever disease is targeted by their quackery as a an inflexible, almost totalitarian, set of edicts that is designed far less to guide physicians in treating patients based on the most comprehensive synthesis of existing scientific and clinical evidence than to “censor,” “silence,” and “cancel” brave “mavericks” like them. Moreover, most medical consensuses express sufficient uncertainty that there is often a fairly wide latitude for doctors to choose different science-based treatments (or combinations of science-based treatments), and doctors as a group tend to be fairly reluctant to label even obvious quackery as quackery. As Dr. Val Jones wrote back in 2008, when it comes to a lot of quackery, most doctors tend to be “shruggies.” They recognize unscientific and pseudoscientific medical practices as bad, but tend to shrug their shoulders about them as in, “What can I do?” (or, worse, “What do you expect me to do about it?”)

As a group we’re way too willing to give each other the benefit of the doubt when it comes to promoting dangerous misinformation, longstanding complaint of supporters of science-based medicine. As I like to say, if you practice so far outside of the medical consensus as to be accused of quackery and spreading dangerous misinformation, you are very far afield indeed from a rather wide, fairly loose set of generally science-based principles governing the treatment of the disease for which your quackery is intended. This was even more true in the early stages of the pandemic, when much less was known about COVID-19, including what might or might not be effective treatments.

I also like to point out that it is true that medicine and the medical consensus evolve—and that’s a good thing! If medicine didn’t evolve we might still be doing radical mastectomies for breast cancer, for instance. It might not happen as fast as we would like, and certainly the whole process is far messier than might be optimal, but medicine does ultimately evolve to embrace practices and treatments supported by emerging scientific evidence. It is also true that medicine is sometimes slow to change in response to evidence. That slowness does not mean that it is scientifically justified to adopt practices like FLCCC’s early treatment protocols and demonization of COVID-19 vaccination, just as the lack of effective treatments for deadly brain cancers like diffuse intrinsic pontine glioma (DIPG) is justification supporting the use of Dr. Stanislaw Burzynski’s antineoplaston quackery.

There is also an element of projection in these narratives. Quacks portray the supporters of medical consensuses as unthinkingly dogmatic and riddled with conflicts of interest, both ideological and financial. Those same quacks often profit handsomely from their quackery, with the FLCCC having constructed a whole business model based on their unproven protocols. Indeed, Dr. Kory himself, in a rant about his potential decertification in which he portrays the ABIM as his enemy, rife with financial conflicts of interest and acting to protect rigid medical dogma, basically admitted as much, albeit not directly:

There is only one silver lining here. One – the impending loss of my certifications does not affect me materially because I have a private fee-based practice due to my need for complete autonomy and lack of restrictions in empirically treating the vaccine injured with various repurposed and alternative therapeutics. I thus cannot and will not accept insurance, and secondly, my academic career is over – no longer will I ever enter back into the system of medicine.

See what I mean? Why should Dr. Kory worry about board certification when he’s raking it in hand over fist from his private cash (or credit card) on the barrelhead medical practice. The only thing he needs to practice is a state medical license, and unfortunately that appears not to be in any jeopardy at all, his carefully cultivated narrative of being a “persecuted” visionary notwithstanding. Moreover, Dr. Kory’s conflict of interest is perhaps more blatant than even doctors taking cash to speak for big pharma in that he has not only a financial interest in his quackery, but an emotional one as well in which he views himself as a superhero fighting medical orthodoxy in order to save lives, which is as good a time to remind you of some of the merch he sells in addition to the FLCCC protocol:

Basically, the FLCCC narrative is the same as that of quacks everywhere, one that portrays the quacks as heroic scientific visionaries persecuted by small-minded doctors riddled with ethical and financial conflicts of evidence because only they are willing to challenge medical and scientific consensus in order to help patients. It’s a classic conspiracy theory narrative, in which nefarious forces and their minions (in this case, doctors who support the scientific consensus and recognize quackery like that of the FLCCC when they see it) are doing evil and trying to “persecute” and “silence” the heroic doctors who have hidden knowledge about what is really going on, all in order to “cancel them.”

Same as it ever was—unfortunately.