White Coat Underground

Before I assume anything about a doctor, I always check to make sure they're really a doctor.  Jon Kaiser is an M.D. in northern California. He graduated from a real medical school where he apparently performed well.  According to the state medical board, his license is current and he has no official actions against him. He has reported to the state board that he is not board certified in any specialty, but claims non-boarded specialty status in internal medicine and infectious disease. He reported to the board and listed on his CV that he has one year of post-graduate training.  I'm not sure how one can claim to be an internist without specialty training, but he does. 

To specialize in internal medicine requires three years post-graduate training, and to specialize in infectious diseases generally requires an additional 1-3 years of post-graduate training. It's not unheard of for older HIV specialists to not have formal infectious disease training---many of them were internists who invented the field of HIV medicine out of necessity when the epidemic first appeared. But to practice internal medicine or infectious disease with only one year of post-graduate training (an internship probably) is very, very unusual.  My state currently requires completion of two years of post-graduate training in a certified program, although since two year programs are vanishingly rare, most licensed physicians will have at least three years.   In the old days, a doctor could finish an internship and hang up a shingle as a family doc.   But even back in the 80s, internal medicine had become far too complex to rely on just an internship.  Hell, my dad graduated from medical school in 1949 and even then internists were expected to compete a full residency program.

This doesn't mean Kaiser isn't a good doctor, but it raises the bar on any claims he makes.  If I know that someone is a boarded internist and infectious disease specialist, and is published in her fields of specialty, I'm likely to require a bit less as far as proving his or her credibility. Someone who completed a brief course of post-graduate training and declares themselves to be an expert will require a lot more to convince me of their expert status.

Most HIV specialists are infectious disease specialists first, and if they belong to a professional organization it is usually the IDSA or the HIVMA. His CV lists him as a member of the American Academy of HIV Medicine.  I'm not familiar with their work, but their website has some useful information. Included is a verification engine to see if a doctor is a member: Kaiser  is not listed on their verification site. He lists himself as being on multiple boards, so I'm assuming this is a glitch in the system.  He also lists himself as a founding member of the California Academy of HIV Medicine, an organization I cannot yet find on the web.  I asked his publicist about this and this was Dr. Kaiser's response:

As a founding member of the American Academy of HIV Medicine, I was intimately involved in setting policy objectives for the organization in its early development phase beginning in 2000. I formed the Academy's Reimbursement Committee in 2000, and was quoted in the attached AAHIVM newsletter (see middle column, paragraph #2). I have also been certified as an HIV Specialist by the organization on two separate occasions (see attached). It appears my membership to the national organization and California chapter inadvertently lapsed when I moved offices. This has been corrected and my membership is now currently active.

Well, I guess that explains the discrepancy between his CV and the professional organization he claims membership and leadership experience in.  Unfortunately they didn't find me a link to the CAAHIVM.  Perhaps they don't have a website.

Anyway, I was curious about the publicist's claim that Kaiser is a major player in the HIV community, so I did a PubMed search. It turned up three references.  I guess one can be a respected HIV clinician rather than a researcher, and that would certainly not show up in PubMed.  But that leads to another problem.  

Kaiser bills himself as "combining the best of natural and standard therapies" for HIV disease. I have no reason to doubt this, but since his approach is unorthodox and he isn't an active researcher I'm not sure how he knows that his treatment is so good.  He does claim some pretty spectacular results:

Though long term stability in my patients has always been the rule, I can now definitely say that the progression of HIV disease in my practice is an extremely rare event. This experience, which has encompassed the care of over 500 HIV(+) patients during the past five years, allows me to make the following statements: Not one patient who has come to me during the past six years with a CD4 count of greater than 300 cells/mm3 has progressed to below that level. Not one patient who has come to me during the past six years with a CD4 count of greater than 50 cells/mm3 has become seriously ill or died from an HIV-related illness. 

This extraordinary level of good health and stability does not come without hard work. My patients follow an aggressive program of natural therapies to support their immune systems. They have also benefited tremendously from the new drugs, lab tests, and other recently released treatment options. What a difference a few years has made!

That seems pretty impressive to me, for a few reasons. In many circumstances, someone who has gathered this much favorable data would have published it.  Without seeing the data in a peer-reviewed journal, there's no way to verify the validity of these claims, or the reason for them.  If the data are accurate, perhaps he attracts a very medically-adherent population.  At many of the HIV centers I'm familiar with, patients often have financial, social, and psychiatric barriers to care, and results aren't so rosy.  So what's this guy's secret?  Does he have a really, really compliant set of patients, or is he doing something different, something not yet well-represented in the HIV literature?

According to him, the secret is his "comprehensive" approach:

I define a comprehensive approach as one which adds a program of aggressive natural therapies and emotional healing techniques to the standard medical treatment of an illness or condition. An aggressive natural therapies program includes a combination of diet therapy, vitamins, herbs, exercise, and stress reduction. Emotional healing encompasses a proactive program of psychological healing techniques that ideally includes a spiritually-oriented practice (prayer, meditation, yoga, etc.) combined with a significant level of social support.

That's a bold statement.  He claims extraordinary results, and claims that a raft of disproved therapies are the answer. If, as he claims, this approach is especially beneficial to those who cannot tolerate proven therapy with anti-retroviral drugs, he really should be working off data, data that show that his approach is safe and effective.   

(1) the micronutrient group had a lower CD4 count at baseline when compared with the placebo group (CD4: 357 ± 154 cells/μL vs. 467 ± 262 cells/μL, P = 0.13), (2) the participants in the micronutrient treatment group reported a greater number of months of neuropathy symptoms preceding enrollment than those in the control group (means: 21.4 months vs. 12.2 months, P = 0.14; medians: 14.2 months vs. 2.5 months), and (3) the micronutrient treatment group contained 3 patients with diabetes mellitus compared with zero in the placebo group (P = 0.09).

It is technically correct that most of these differences were not statistically significant, but, look at the results:

The mean absolute CD4 count increased significantly by an average of 65 cells in the micronutrient group versus a 6-cell decline in the placebo group at 12 weeks (P = 0.029)

CD4 counts vary quite a bit, and are an imperfect measure of disease activity and immune function.  As we can see from his groups, there was a very large range of CD4 counts in each group at the start.  An average change in CD4 count of 65 seems anemic at best. Kaiser is more optimistic:

This study demonstrates that a micronutrient supplement administered to HIV-infected patients taking stable HAART significantly enhances CD4 lymphocyte reconstitution. Our findings support the potential for a broad-spectrum micronutrient supplement to be used as adjuvant therapy in combination with HAART to provide patients with a more robust CD4 cell rebound after initiating antiretroviral treatment. 

I find the data from this pilot study entirely unconvincing.  His conclusions are hyperbolic and premature.  That's not unusual, though.  Researchers sometimes get a bit excited about their work, and as an inexperienced author, perhaps he can be forgiven for a little unrestrained enthusiasm.

But it gets a bit more interesting that that.  In a letter to the editor, a careful reader noted something unusual.  A patient showed him a brochure claiming that K-PAX could raise CD4 counts by 26%.  K-PAX, it seems, is the same product used in Kaiser's study. The writer was concerned:

Most disturbingly, the first author on the paper, Jon D. Kaiser, MD, seems to be the same person mentioned in the brochure as the developer of K-Pax Vitamins. 

Given the recent controversies at other medical journals about the failure of authors to disclose potential conflicts of interest, I am sure that this article would not have been published without disclosure (or at all) if the Editors had been aware of the conflicts of interest in this case.

There is a long, sordid history of conflicts of interest in published research.  Some drug companies have gone so far as to print their own faux-journals containing only favorable studies.  That is why most journals have strict disclosure rules for conflicts of interest. A study being sponsored by a drug manufacturer does not invalidate it, but failure to disclose this connection is unethical and problematic on many levels.
Kaiser was (correctly) allowed to respond:

 

After reporting the improved immune reconstitution of patients taking the micronutrients plus highly active antiretroviral therapy (HAART) to the Bristol-Myers Squibb team, I anticipated that they would show interest in pursuing the development of a therapy that had the potential to act as a safe and beneficial immune modulator.

On learning that they had no interest in pursuing the development of this compound, I chose to form a company, K-PAX, Inc., to keep the micronutrient supplement in production and make it available for sale while I worked to get the study results published.

I neglected to inform the Editors of this journal of this conflict of interest and any potential bias that existed during the paper's submission and publication process. Nor did I inform the other authors on the paper of my financial interest in the company. They received no personal compensation for their efforts.

In other words, he is the guy who makes and sells K-PAX, and he owned up to failing to disclose this profound conflict of interest. I asked Kaiser through his publicist about this. His response was less conciliatory:

 

This research study was performed before there ever was a company or financial interest in a product (2001-2003). The data were analyzed by an independent Data Analysis Firm selected by Bristol-Myers Squibb in 2001. The JAIDS editorial board performed a thorough evaluation after Dr. Smith raised his concerns and found no evidence that either the data analysis or study conclusions were inaccurate.

I'm unimpressed by this response.

As I've said many times in this space, being wrong is not a moral failing---being deceptive is.  Many doctors who offer unproven therapies are genuine in their beliefs that they are doing good.  This doesn't change the fact that promoting unproven treatments is a bad thing.  A doctor should know better than to use hyperbolic language to convince HIV patients that he somehow has the answer to their disease, an answer that no other specialist has.  Of course, most doctors have a lot more formal training that Dr. Kaiser, so perhaps he can be forgiven for his hyperbolic promotion of a single pilot study as a major breakthrough in HIV treatment.

Right?