Source: http://www.lakesidepress.com/Asbestos/ATS-biases.htm
Timestamp: 2018-09-22 13:13:20
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Asbestos, asbestosis, mesothelioma, lung cancer, interstitial fibrosis, chrysotile, amphibole, asbestos fibers, litigation, B-Reader, amosite, crocidolite, pipe fitters, boiler makers, insulators, pleural plaques, pleural fibrosis, friable asbestos, chest x-ray, CT scan, lung biopsy, litigation, RAND corporation, AMA, ACCP, ATS, ACR, radiology, consensus statement, attorney, lawyer, plaintiff, Chest, ATS bias, junkscience, ACCP, Lester Brickman, Pepperdine Law Review, Tee Guidotti
ATS Bias:
Origins of Anti-Science in the 2004 Official Statement on Asbestos Diagnosis
For Adobe format of this and related sites, see:
The 2004 ATS Statement on Asbestos Disease Diagnosis: Scientific and Ethical Problems
Dr. Homer Boushey
Dr. Gunner Hillerdal
Dr. Gregory Wagner
Anti-science and the ATS
INTRODUCTION. The ATS 2004 Official Statement Diagnosis and Initial Management of Nonmalignant Diseases Related to Asbestos (Amer Jour Res Crit Care Med 2004;170:691-715) is cleverly crafted so as to support diagnosing benign asbestos disease subjectively, for profit, by plaintiff attorneys and their medical shills. The origin of this anti-science position is the provable bias of several ATS officials and Statement authors, discussed below. Two other web sites detail unscientific aspects of the article:
Asbestos Diagnosis: ATS Official Statement 2004 -- a Flawed & Biased Statement
Asbestos Diagnosis: ATS Official Statement 2004 -- Omitted References
I have also authored an 'Open Letter' to ATS, succinctly pointing out the problems detailed in this and the other two web sites, and offereing a solution.
Using publications of a few ATS officials/authors, this web site shows how individual bias influenced the ATS article to make it unscientific. (Every underlined word or phrase is an important link to another web site or document, so I do not recommend reading this as a paper printout.) None of this information was disclosed in the ATS article. Indeed, there was NO disclosure (financial or otherwise) for any of the authors, though AJRCCM normally requires author disclosure for everything in the journal (including letters).
Dr. Thomas Martin, ATS President, 2002-03
In 2003 Dr. Thomas Martin (no relation) wrote the American Bar Association after the ABA adopted a policy that would recognize asbestos claims only if they met specific medical criteria (click here for complete ABA proposal). Dr. Thomas Martin (I will use his first name, to distinguish him from this author) wrote a response to Dennis Archer, JD, ABA President-elect. In this letter he makes statements that have no medical foundation. He wrote "The medical criteria used in the [ABA] document do not reflect the current state of screening and diagnosis for asbestos-related diseases." He did not acknowledge the "current state," as if he was unaware of the asbestos scam being run by plaintiff-attorney-hired B-readers.
Dr. Thomas Martin's letter to the ABA suggests that people making the screening diagnoses adhere to some objective criteria, which was (and is) far from the truth. (Read Section A: Litigation Screenings, in the ABA document.) He wrote: "significant asbestosis can be present with an x-ray profusion less than 1/0 or even with a normal chest x-ray." What does this mean? That if an attorney-hired B-reader reads a normal chest x-ray as "significant asbestosis," that's acceptable? That because some autopsies have shown changes of asbestosis when the chest x-ray did not, that anything goes in diagnosis? This has to be one of the most inane comments ever to appear from the ATS. It is anti-science. His letter can only be interpreted as supportive of the asbestos screening status quo -- an attorney-run program that has been described as a "scam," "swindle," and "fraud". There's more evidence of bias in his letter, discussed by Dr. Renn in a letter-to-the-editor of AJRCCM.
Dr. Joseph J. Renn wrote a strong letter to AJRCCM, which their editor at the time published. Dr. Thomas Martin's reply, which follow's Dr. Renn letter, is defensive and bureaucratic in tone. It really does not answer Dr. Renn's criticisms, but does convey an attitude: 'We are the experts. If ATS states something, it must be so. Don't challenge us.'
Dr. Homer Boushey, ATS President, 2003-04
In 2003 Dr. Boushey wrote a letter to Senators Orrin Hatch and Patrick Leahey, as the U.S. Senate was preparing to debate asbestos legislation. Dr. Boushey's letter is crafted so as not to hinder the process of compensating claimants without provable disease. He wrote:
"The ATS does not have a position on the need for, merits of, or construction of asbestos litigation reform legislation."
Why not? The diagnosis of asbestosis is being made by a completely unscientific screening process, a process that has created a phony epidemic of asbestosis and along the way disrupted major portions of our legal and business fabric. At the same time, ATS has taken on the task of authoring an Official Statement on Diagnosis of nonmalignant asbestos disease. And Dr. Boushey says the ATS has no position? For ATS to not have a position on this diagnostic process is tantamount to endorsing it.
In his letter Dr. Boushey also wrote: "Evidence supporting the link between asbestos exposure and colon cancer is at least as strong or stronger than evidence linking asbestos exposure and stomach cancer." In fact there is no hard evidence to support this statement, and even the final Official Statement did not come out this strong; it states (p. 711, 4th para.): "Studies suggest that there may be an elevation in the risk of colon cancer, although this remains controversial." Why didn't Dr. Boushey tell Senators Hatch and Lahey that a link was "controversial"?
Finally, Dr. Boushey wrote: "The effect of asbestos is to more than double the risk of lung cancer among smokers, even though these are people who are already at risk for lung cancer from their smoking." Dr. Boushey doesn't acknowledge the debate over whether asbestosis has to be present to implicate a role in lung cancer, or explain just what he means by "effect of asbestos." If a plaintiff's lawyer says his client with a 50-pack-year smoking history and lung cancer worked around asbestos, is that sufficient? If a plaintiff B-reader mis-interprets chest wall fat as asbestos pleural thickening, is that sufficient? How does one compensate a heavy smoker with lung cancer when there is no objective evidence for an asbestos condition (objective defined as not coming from people paid for their diagnosis). Like others quoted in this web site, Dr. Boushey seems to abandon rationality and science when it comes to asbestos diagnosis.
Dr. Michael Harbut, one of the ATS Official Statement's 11 Authors
Of all the physicians discussed in this web site, Dr. Harbut has perhaps been the most vocal in his socio-polical beliefs regarding asbestos. In 2000 the American College of Chest Physicians endorsed the The Fairness in Asbestos Compensation Act, an industry-backed bill designed "to streamline the compensation process for asbestos victims." The bill was approved by the House Judiciary Committee and headed to the full house for consideration. Dr. Harbut, an ACCP chairman of its environmental committee, wasn't consulted prior to the endorsement, and publicly quit the ACCP. In a statement of ultimate irony (considering his co-authorship of the un-scientific ATS Official Statement), Dr. Harbut wrote ACCP:
"The staff and leadership of the ACCP has constructed a fire wall built of asbestos to protect whatever it is they are protecting. There is no interest in ethical behavior. There is no interest in organizational responsibility. There is no interest in medical science. There is no interest in helping patients with asbestos-related disease beyond the proposed law written by an asbestos company attorney."
In a statement from Dr. Harbut promoting a total asbestos ban, he wrote:
"Over the past 12 years I have treated thousands of persons with diseases associated with asbestos."
For anyone who practices pulmonary medicine, this is an astounding statement. I have been in practice almost 30 years, which includes training dozens of pulmonary fellow, working in teaching and non-teaching hospitals, and inner city and suburban clinics. I've also reviewed hundreds of asbestos claims in detail. I don't see how any physician, pulmonary or otherwise, can claim to "have treated" thousands with asbestos disease, when the patients just aren't there. Furthermore, almost none of the asbestos claimants has been under treatment for asbestos disease by their primary care physician, simply because they have no true disease, or documented impairment from asbestos. True asbestosis, a serious condition, is rarely diagnosed today by practicing pulmonologists. And pleural thickening and/or plaques almost never require "treatment" of any sort. If Dr. Harbut alone has treated "thousands of cases," his experience is unique: why doesn't he report it? Assuming his experience was replicated by other pulmonologists, we would have an epidemic. Why isn't it in the medical literature? Because no such epidemic exists. Dr. Harbut has simply invoked obvious (and unjustified) hyperbole to make his case for banning asbestos.
In a January 2000 letter to the American Medical Association Dr. Harbut displayed more bias regarding asbestos diagnosis and compensation. For example:
He wrote: "Although most informed persons feel the existing legal approach is in desperate need of reform, this letter does not speak to the legal matters raised." This is a disingenuous comment, to say the least. THE CAUSE OF THE ENTIRE PROBLEM REGARDING DIAGNOSIS is "the existing legal approach," yet he won't speak to it. He didn't in 2000 and still did not in the 2004 ATS Statement. By ignoring the root cause of the problem Dr. Harbut sets up a straw man, the strict and "arbitrary" criteria in the proposed legislation.
He wrote: "[The proposed bill] defines asbestosis, cancer etiologies in relationship to asbestosis, and sets forth specific criteria to reach these diagnoses....What are patients and physicians to do if the law is in conflict with the science? Or if the science advances more quickly than the legislative process?" This is another disingenuous statement. The plain fact that he chooses to ignore the crucial "legal issues", and has never come out against the anti-science methodology of plaintiff-attorney-driven diagnoses, belies his complaint.
He wrote: "That leaves payment up to everyone except those who caused the illness." Here his bias is most obvious: the assumptions that a) all claims are legitimate and b) those sued "caused the illness." He evidently doesn't know or care about the dysfunctional legal system that generates thousands of bogus claims against companies that never were in the asbestos business.
Dr. Harbut was also co-author of a 2004 letter to Academic Radiology criticizing the Gitlin, et al study of plaintiff B-readers (Acad Radiol 2004;11:1397-9); this letter is discussed in the section on Dr. Guidotti.
Overall, it is apparent that Dr. Harbut has strong biases on asbestos issues, and that they have infused the ATS Official Statement on diagnosis.
Dr. Albert Miller, one of the ATS Official Statement's 11 Authors
Dr. Albert Miller was a colleague of Dr. Selikoff's at Mt. Sinai Hospital in NYC. Dr. Selikoff, of course, alerted the nation to the medical hazards of asbestos, by finding real disease in pipe fitters, asbestos miners and other workers who had suffered close contact with the fiber. Dr. Miller has continued with this research, and has extensive experience in evaluating insulators and other workers heavily exposed to asbestos. Unfortunately (for ATS) he appears to have no experience evaluating claims manufactured by attorneys in mass asbestos screenings (if I'm wrong, it doesn't reflect in his publications). His experience with legitimate cases has led him to a major error of logic:
DR. MILLER'S ERROR OF LOGIC
(a) Radiologic asbestosis can be defined with profusion scores starting at 1/0 (Miller A. Chest. 1998 Jun;113(6):1439-42).
(b) All 1/0 profusion readings by plaintiff attorney hired physicians are accurate (implied throughout ATS Official statement, and specifically by relying on conclusions [page 710, Official Statement] from the junk science study published in Chest by Ohar, et al).
(c) Therefore, any 1/0 profusion reading is presumptively diagnostic of asbestosis (ATS Official Statement; page 696).
Dr. Miller no doubt would object to my parsing his logic this way, but the facts (or quotations) speak for themselves. In my opinion this error of logic is inexcusable, since he clearly knows the literature, the articles that show 1/0 can come from smoking or non-asbestos exposures (see his Response letter in Chest. 1999;115:303-305 - "On Perception, Perspicuity, and Precision."). I am sure Dr. Miller is also aware of the literature showing that plaintiff-attorney-hired B-Readers over-interpret chest x-rays a majority of the time. In July 2003 Drs. Linton and Gitlin wrote, in a letter to Senator Orrin Hatch, results of a study they were to publish the following year:
"...the initial readers [B-readers hired by plaintiff attorneys] interpreted the study radiographs as positive for parenchymal abnormalities with a small profusion category of 1/0 or higher 91.7% of their 551 reports. The consultants [blinded to the origin of the films] interpreted the same set of cases as category 1/0 or higher in only 4.5% of their 3306 reports [6 consultants per x-ray]... we surveyed the world literature on x-ray studies of asbestos-related changes and could find no studies anywhere that reflected the 91.7% percent positivity reported... by the initial readers."
The findings of Drs. Linton and Gitlin were published in early 2004, and could have been included in the 2004 ATS Official Statement (but were left out). Either way (open letter to Senator Hatch, or actual publication), this information had to be known to Dr. Miller. By ignoring it and other relevant studies, Dr. Miller could make his error of logic. He erroneously extrapolated from asbestos disease that he knows and has diagnosed, to the hundreds of thousands of subjective x-ray interpretations made by plaintiff-attorney-hired B-readers who routinely over-interpret films. This simple (and, for a scientist, inexcusable) error of logic led him to co-author the anti-science statements on chest x-ray interpretation in the ATS article.
Dr. Gunner Hillerdal, one of the ATS Official Statement's 11 Authors
Dr. Hillerdal, from Sweden, is an international authority on asbestos, and has been very influential in setting policy in his own country. Like Dr. Miller, he has seen the ravages of asbestos, and has become biased in such a way as to affect his pronouncements on asbestos. In an article on asbestos disease in Sweden, Dr. Hillerdal wrote:
"We can already see how asbestos-related diseases in people exposed to environmental "background levels" of asbestos are increasing, but the risk is much less for these people than for those with heavier exposures."
Like many of his colleagues who resort to hyperbole and unfounded generalization on asbestos diagnoses, Dr. Hillerdal provides no reference for this assertion. Is it based on a scientific study, done by impartial physicians? Or does it come from diagnoses made by plaintiff-attorney-hired B-readers?
Dr. Gregory Wagner, one of the ATS Official Statement's 11 authors
Dr. Wagner is Director, Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health (NIOSH). He testified before the Congressional Subcommittee on Superfund, Toxics, June 20, 2002, regarding health hazards of asbestos. In his testimony (available on the internet) he stated:
"Exposure to asbestos significantly increases the risk of contracting several diseases. These include:
1) Asbestosis...
2) Lung cancer - for which asbestos is one of the leading causes among non-smokers, and which occurs at dramatically high rates among asbestos-exposed smokers:
3) Malignant mesothelioma...
4) Nonmalignant pleural disease...
In addition, asbestos exposure is associated with excess mortality due to cancer of the larynx and cancer of the GI tract.."
Dr. Wagner's main point was to draw attention to the horrible consequences in Libby, Montana, where vermiculite caused a high rate of true asbestos-related diseases (from tremolite asbestos, which makes up about 10 to 20% of the fibrous materials in vermiculite). Nonetheless, by using gross exaggeration and generalization, he shows his bias on asbestos disease. Specifically:
Lung cancer DOES NOT occur at dramatically higher rates among asbestos exposed workers, if one defines "asbestos exposed" as anyone who ever worked in a location where asbestos was simply in the vicinity (i.e., in the pipes, walls, stacked in the shipping department, etc.). It is actually controversial about whether the lung cancer risk is increased with any asbestos exposure in the absence of true asbestosis. Medical journal articles can be found on both sides of this issue. The real problem is that the phrase "asbestos-exposed" has been cheapened by the asbestos screening claims to the point of meaninglessness, and should not be used without qualification - especially by scientists or authors writing for the ATS.
Dr. Gregory knows the importance of qualifying the phrase "asbestos-exposed." He was quoted in a Montana newspaper regarding asbestos hazards:
"The most obvious and serious contributing factor is smoking...combination of smoking and asbestos exposure creates a muliplicative chance for lung cancer. That number [of lung cancer cases] is going to depend on the intensity of exposure."
In other words, there are varying degrees of exposure, and without qualification (and, in a legal claim, documentation) "asbestos exposure" conveys no useful information. Nonetheless, the unqualified phrase "asbestos-exposure" appears in the ATS article in the context of cancer risk. The faulty reasoning is by now familiar -- extrapolation from real and deadly disease (e.g., Dr. Selikoff's original cohort of insulation workers; the Libby, Montana workers) to hundreds of thousands of cases manufactured solely for the purpose of filing claims. Intuitively, even without firsthand experience in evaluating bogus claims, the ATS authors must know that not all the claims made by PAHP can be legitimate, that not all the 1/0 readings can be substantiated, that not all the hundreds of thousands of workers had significant exposure to friable asbestos. If that is the case, then the only reasonable explanation for allowing unwarranted generalizations and misstatements into the article is bias.
Dr. William Beckett, Advisor to the ATS Statement committee
William Beckett, M.D., M.P.H., University of Rochester, assisted the 11 authors in preparing the ATS Statement, and was acknowledged in the credits on page 712. Dr. Beckett is well known in academic asbestos circles for his expertise. Unfortunately, he shares the same biases as the other physicians quoted above, and so contributed to the anti-science, plaintiff-oriented slant of the Official Statement. An example of this bias showed up in a 1997 editorial he wrote for Chest. Chest published back to back editorials regarding the diagnosis of asbestosis. David Rosenberg, M.D., M.P.H., a practicing pulmonary specialist in Cleveland, wrote in favor of uniform criteria for the diagnosis, specifically:
1) "asbestos exposure of significant intensity of duration and latency must have occurred."
2) "it is imperative to confirm that fibrosis exists."
3) "the exclusion of confounders for the presence of pulmonary fibrosis."
As part of his argument, Dr. Rosenberg quoted a 1991 paper (Gaensler EA, Jederlinic PJ, Churg A. Idiopathic pulmonary fibrosis in asbestos-exposed workers. Am Rev Respir Dis. 1991;144:689-96) which showed open lung biopsies did not confirm 5.1% of clinically and radiologically-diagnosed asbestosis. Dr. Rosenberg wrote:
"As Gaensler pointed out, while the prevalence of nonasbestos-induced interstitial lung disease in this select study population was low (5.1%), the future occurrence of such cases will be increasing because asbestosis is a disappearing disease."
After further discussion of his recommendations, Dr. Rosenberg observed:
"...due to inaccurate diagnoses, far fewer individuals probably have asbestos-related diseases than are implied by the number of personal injury claims that have been made. Consequently greater specificity should be utilized in the clinical diagnosis of asbestos-related disorders....Arguments of legal attributability, which focus only on a few "selected" asbestosis criteria while negating or failing to consider others, lowers the predictability below acceptable standards for diagnosing asbestosis. Under such circumstances, the likelihood of an individual having asbestosis is too uncertain for sound legal or policy judgments."
The opposing editorial by Dr. Beckett exemplifies the same error of logic made by Dr. Miller and others on the committee. He extrapolates from real disease, diagnosed by treating (and usually academic) physicians, to the population of bogus claims created by the plaintiff-attorney-machine. The real disease in the Gaensler study was profusion of 1/1 or greater, i.e., disease that met the 1986 ATS criteria for asbestosis. Thus Dr. Beckett wrote:
"These clinical criteria [referring to the 1986 ATS criteria, profusion at least 1/1 for asbestosis] were tested against the gold standard of lung biopsy [Gaensler, et al]. The study found an approximately 95% false-positive rate for the clinical criteria, i.e., that 95% of the clinically diagnosed cases did indeed have asbestosis, and 5% had other disease."
From this comment he argues there is no sound reason to do open lung biopsies, and then states [italics added]:
"The problem of overdiagnosis, if it exists, is not any failure of these criteria, but only failure to apply them."
The irony of this comment should not be lost on the reader. It shows a logical inconsistency for Dr. Beckett, and raises some important questions. I will pose these questions on the internet, and wait for Dr. Beckett's response.
1) Dr. Beckett, you promulgated profusion of 1/1 as the entry level for diagnosing asbestosis in 1986, and again in the 1997 editorial. What happened that caused you to change to a profusion of 1/0 in 2004? (No explanation was provided in the 2004 Official Statement.)
2) Were you really, honestly not aware in 1997 that there was a major problem in over-diagnosis of asbestosis by plaintiff-attorney hired B-readers? What made you express doubt in 1997 ("if it exists")? Along the same line, how do you reconcile Dr. Gaensler's comment in 1991 ("...because asbestosis is a disappearing disease, such cases [clinical asbestosis found to be something else when the lung is biopsied] will become more frequent") with the explosion of asbestosis claims since then?
3) What percentage of positive biopsies do you estimate would be found today if EVERY ASBESTOS CLAIMANT solicited and diagosed by the plaintiff-attorney-screening process was to have an open lung biopsy? More than 5%? How much more? Would you ever put your name to the figure? (This is another way of asking you what percentage of these asbestosis diagnoses do you believe are real.)
4) Finally, why have you never written or acknowledged the basis for which Dr. Rosenberg wrote that 1997 editorial in the first place: The anti-science method of diagnosis employed by the plaintiff-attorney-screening process?
Dr. Jerrold Abraham, Advisor to the ATS Statement Committee
There is scientific disagreement in the medical literature over whether the evidence supports asbestos as a cause of lung cancer when there is no asbestosis (i.e., no pulmonary fibrosis, or definite lung scarring from asbestos). In 1994 Dr. Abraham entered the debate with "Asbestos inhalation, not asbestosis, causes lung cancer," (Abraham JL, Amer J Ind Med 1994;26:839-42), and he has presumably held this view ever since.
In 1999 Dr. William Weiss published a review of the relevant literature, and wrote: "Much debate has resulted over the hypothesis that excess lung cancer risk occurs only among those workers who develop asbestosis, some favoring the hypothesis [Churg, A (1993) Asbestos, asbestosis, and lung cancer. Mod Pathol 6,509-511; Jones, RN, Hughes, JM, Weill, H (1996) Asbestos exposure, asbestosis, and asbestos-attributable lung cancer. Thorax 51(suppl 2),S9-S15; Browne, K. Is asbestos or asbestosis the cause of the increased risk of lung cancer in asbestos workers? Br J Ind Med 1996: 43,145-149] and some opposing it [3 articles cited, including Dr. Abraham's 1994 paper]."
From his review Dr. Weiss concluded: "the evidence indicates that asbestosis is a much better predictor of excess lung cancer risk than measures of exposure and serves as a marker for attributable cases." In essence, Dr. Weiss's review disagreed with the conclusions of Dr. Abraham and others. Neither Dr. Weiss's paper nor references 21-23 were listed among the articles were listed among the articles cited in the Official Statement when it discussed asbestos exposure and lung cancer. Several news accounts also document Dr. Abraham's strong environmental views and criticism of government inaction on asbestos issues (Seattle news artlcle; News&action article; Mesothelioma Research article). I am not critical of his positions, but only point out that they are in concert with the other architects of the ATS article, and confirm lack of any balance on the ATS author committee.
Dr. Tee Guidotti, head of Occupational Medicine at George Washington University, and Chairman of the Committee that wrote the ATS Official Statement
Like Dr. Harbut, Dr. Guidotti has also been very vocal about asbestos issues. When the American College of Chest Physicians endorsed In 2000 the American College of Chest Physicians endorsed the The Fairness in Asbestos Compensation Act in 2000, he also objected and "sent a letter to executives of the organization to say he was not renewing his membership because of the way the group handled the endorsement."
Dr. Guidotti came to Washington, D.C. from Canada, and in 2001 wrote a letter favoring a total asbestos ban in that country. In this letter evident bias is two-fold. First, he wrote:
"A smoker exposed to asbestos is more than twice as likely as a smoker who was not exposed to asbestos to die of lung cancer (whether there is a synergistic effect at that level of exposure or not), a conclusion supported by the totality of the literature and individual studies of chrysotile-exposed workers in which the data have been so analyzed."
Dr. Guidotti's "totality of the literature" to support this statement is a SINGLE study in the British Journal of Industrial Medicine in asbestos factories in China! If that was the only extant study, his statement might not seem so unreasonable. In fact, though, he omits other studies that argue strongly to the contrary. (Note that this type of non-supported, key-references-omitted statement presages the style of the 2004 ATS Statement.)
Second, Dr. Guidotti argues that if this association was recognized, "many claims now denied would be accepted [from] smokers who were exposed to asbesos and developed lung cancer." He never explains how "exposed to asbestos" would/should be interpreted, leaving the door open to whatever the claimant/plaintiff attorney/plaintiff expert want it to be. He must know that many claims are made simply because the worker and some asbestos product were located in the same plant, not because there is any evidence of actual exposure to friable asbestos.
In 2002 Dr. Guidotti published a review article, Apportionment in Asbestos-Related Disease for Purposes of Compensation. His review is notable for its clear bias toward expanding workers' compensation claims for asbestos-exposed workers. It is really an extended editorial, in which he tries to show how one can 'prove' asbestos causation when exposed workers who smoked develop lung cancer or airway obstruction. He makes his argument using selective referencing, unwarranted assumptions, and some misleading statements. This is not the place to rebut his article point by point; anyone with a pulmonary background can read it and come to his or her own conclusions. However, I will mention a few items that justify my overall criticism:
page 298: he references an article on how bias in one state (Washington) reduced acceptance of legitimate asbestos claims, but never addresses the opposite: how bias in asbestos screenings may increase illegitimate asbestos claims;
page 306: he assumes that loss of FEV-1 greater than predicted (over time) confirms airway obstruction from asbestos inhalation, when FEV-1 decrement is not, per se, a marker for airway obstruction
page 307: he promotes a "crude rule of thumb" to apportion loss of respiratory function between smoking and asbestos, as follows:
"50% apportionment to asbestos and 50% to cigarette smoking... This method has the advantage of simplicity but cannot take into account degrees of exposure or smoking history. It is probably an overestimate (thereby "giving the benefit of doubt to the worker", appropriate to workers' compensation) since it is unlikely that asbestos exposure would be responsible for as much as 50% of isolated obstructive impairment."
There is no reference for his phrase "giving the benefit of doubt to the worker," though he put it in quotation marks. It seems to be his mantra, his bias, and it infuses everything he writes on asbestos -- including the supposedly-objective 2004 ATS Official Statement.
Everyone has biases, beliefs, attitudes on contentious issues -- by definition that's what makes them contentious. As long as Drs. Guidotti, Harbut and others confine them to letters or editorials, without official ATS imprimatur (and with full disclosure), readers should not be mis-led into assuming their comments reflect objective, non-partisan analysis. My criticism is that these blatant biases have influenced the supposedly-objective ATS "Official Statement" so as to render it non-objective and non-scientific: by frequent use of unsupported statements on x-ray diagnosis; non-explanation of profusion standards; omission of key references; etc.
Dr. Guidotti's association with Dr. Laura Welch is also important in highlighting what he, as Committee Chairman, left out of the ATS Official Statement. Dr. Welch is an adjunct professor in Dr. Guidotti's department at GW, and also head of The Center to Protect Workers Rights, in Silver Spring Maryland. In 2004 she filed an "Expert Report", presumably for legal purposes. It is included here in three parts (Part 1; Part 2; Part 3).
Dr. Welch's report is an important document for what it reveals about the mindset of physicians with an 'asbestos agenda'. It clearly allows for an "anything goes" approach to asbestos diagnosis, which fits perfectly with the play book of plaintiff attorneys.
Part 1, page 7: "...therefore a 1/0 film in an asbestos-exposed worker is consistent with asbestosis." She doesn't state or even imply that 1/0 may be found from other causes completely unrelated to asbestos. Nor does she clarify what "asbestos-exposed" means. Working in a factory where asbestos was in the pipes? Working in the shipping area with no documented exposure to friable asbestos? Does it matter that the vast majority of asbestos claimants do not have a job description that would have exposed them to friable asbestos? Does she believe in any standards to define "asbestos-exposed" for an individual claimant?
Part 1, page 8: "...experts agree that the x-ray alone should not be used to make a diagnosis of asbestosis; the examining physician should use the occupational and medical history, results of pulmonary function testing, and other medical data to reach a diagnosis." She doesn't state anything about how plaintiff attorneys, using non-treating physicians paid specifically for the purpose, have used just a single reading on a single chest x-ray to make this diagnosis tens of thousands of times.
Part 2, page 12: "It is my opinion that a 1/0 classification of an x-ray, using the International Labor Organization Classification for Pneumoconiosis, is sufficient for the diagnosis of asbestosis when used as defined in the TDP." TDP is decoded in Part 1 as the "draft Owens Corning Personal Injury Settlement Trust Distribution Procedures (TDP)," and is not otherwise clarified or defined. Then on page 13, in a classic example of a circular argument, she writes that "the ATS Document [i.e., Dr. Guidotti's Committee's Official Statement] states... a profusion of irregular opacities at the level of 1/0 is used as the boundary between normal and abnormal in the evaluation of the film..."
Thus it is fair to say that, in her opinion, '1/0 diagnoses asbestosis' in an asbestos-exposed worker. Nothing about the credibility of the exposure history, other causes of 1/0 profusion reading, or reliability of that reading. Hardly an objective approach to asbestos diagnosis. But what really shows her anti-science bias are comments made about three defense-oriented works:
Study by Dr. Gary Friedman for Owens Corning, a defendant in asbestos litigation [Welch Report - Part 2]
Gitlin, et al study of plaintiff B-reader reports [Welch Report - Part 3]
Law review article by legal scholar Professor Lester Brickman [Welch Report - Part 3]
Drs. Gitlin and Friedman both found asbestos disease over diagnosed by plaintiff-attorney-hired physicians. Attorney Brickman, referencing numerous legal documents, lays bare the asbestos screenings for what they are, a massive scam. Needless to say, Dr. Welch doesn't buy their conclusions. In her criticism of Dr. Friedman (Part 2, page 15) she writes "Dr. Friedman reaches several conclusions that cannot be supported by the data he reviewed," and then provides a point-by-point analysis. It is her attempt at critical analysis, rather than the specifics, that are important here. Hold that point for just a moment.
Regarding the Gitlin and Brickman study, Dr. Welch again is highly critical, and makes some specific statistical arguments to challenge their findings (Part 3). For the Gitlin, et al study, she and Dr. Harbut, along with Dr. Christine Oliver of Harvard Medical School, co-authored a rebuttal letter (original letter in Part 3; published in Acad Radiol 2004;11:1397-9). In their letter they take issue with: how Dr. Gitlin chose his consultants to review the plaintiff chest x-rays; how the original set of 551 films was chosen; the fact that the consultant readers disagreed among themselves as well as the initial B-readers, etc. In other words, they wrote a scientific response to a scientific article. The kind you read all the time in medical journals. Dr. Gitlin and his co-authors answered their (and others') criticisms item by item (Acad Radiol 2004;11:1402-4).
So, what's the point? Just this. Drs. Harbut, Welch, Oliver, Guidotti, et. al. have NEVER critically analyzed the plaintiff-attorney-sponsored diagnostic screening process. Then, when someone does this (i.e., Friedman, Gitlin et al, Brickman), they jump all over them, with detailed analysis. Extreme bias is evident in their implied assumption that the plaintiff-attorney-sponsored screening process is beyond reproach (implied because they have never analyzed or criticized it). For Drs. Harbut, Welch and Oliver to criticize the methodology of people like Dr. Friedman, Dr. Gitilin, and Professor Brickman, and never to criticize the methodology of the plaintiff-attorney-screening process, is hypocrisy borne out of bias. It is this same pseudo-objective, hypocritical attitude that is evident throughout the ATS Official Statement.
A second issue related to Dr. Welch's Expert Report is that experts in asbestos (Dr. Guidotti and his committee, for sure) were well aware of the work of Drs. Friedman and Gitlin, and Mr. Brickman, but chose to omit any mention of them in the ATS Official Statement. Dr. Welch at least thought it important to try to counter their conclusions (conclusions which undermine the very foundation of the asbestos scam, not to mention much of ATS's Official Statement). Surely their work at least merited a mention by ATS. Was it omitted because of lack of space in a 26-page article with 160 references? Or bias?
IN SUMMARY, it is apparent from all the documents linked to or quoted above, that key ATS physicians are very opinionated regarding asbestos legislation and patient advocacy issues. Again, I am NOT critical of anyone for having socio-political opinions regarding asbestos. I am critical that these biases have allowed an important article to become non-scientific, non-objective. I am critical that this article is written from a single viewpoint, one that (through selective referencing, unsupported statements, etc.) distorts the truth of what we know about asbestos diagnosis.
If, say, just half the Committee and its advisors share the strong pro-plaintiff views of Drs. Harbut and Guidotti, and the other half is neutral or has no bias, there would be no 'check and balance' to keep these opinions from influencing the ATS Statement. Thus it was that individual biases, unchecked by opposing viewpoints, coalesced so that the authors left science at the door in crafting its Official Statement.
As for the other physicians and scientists associated with the ATS Statement, none (to my knowledge) has ever written anything critical or even analytical of the asbestos screening process, or acknowledged (in public, at least) that it is unscientific. It seems that every asbestos "expert" at the prestigious, supposedly-science-oriented American Thoracic Society is content with the anti-science methodology described below.
My charge is very specific. Otherwise reputable physicians and scientists have abandoned science because of their political and economic biases over asbestos. In their quest to pursue an "agenda" on asbestos, they have winked at or ignored flagrant violations of scientific principle. Their bias has distorted an important review article, and sullied ATS's credibility in the one area where it is most needed.
Imagine if these ATS physicians and scientists were asked to justify, in a public forum of peers, a method to find out who has benign asbestos disease. Would they promulgate, support or even try to justify the following method?
METHODOLOGY TO DIAGNOSE BENIGN ASBESTOS DISEASE
Use only a handful of B-readers, hired and paid by lawyers who stand to profit from every positive diagnosis. This group of B-readers will read chest x-rays of factory workers and ex-workers solicited by lawyers for the single purpose of filing lawsuits. There will be no control x-rays to read, and no outside audit of the results. Each hired B-reader will know four things about the study before beginning:
a) he will not be shown films of people who claim no asbestos exposure;
b) the lawyers wish every film to show asbestosis or asbestos pleural abnormalities if such an interpretation is at all possible;
c) he will get paid more for a positive diagnosis than for a negative one;
d) if he pleases the attorneys he can read hundreds or thousands more films, and make a ton of money.
What you have just read describes the methodology in place today. Yet ATS ignores it. Indeed, by making unsupported statements regarding x-ray diagnosis, by selective use of references, by omitting information that documents the screening asbestos scam, ATS has given its imprimatur to this anti-science methodology. If ATS see no problem with this methodology then the organization has truly abandoned science when it comes to asbestos diagnosis.
As pointed out in another web site, one feature of true junk science is that the perpetrators don't respond to the challengers. They hide behind their credentials or official announcements. However, there may be one or two ATS Statement Committee members or ATS officials with integrity enough to give it a try. In that unlikely event, I will pose a few simple questions.
Why wasn't anyone on the ATS Committee with experience in defense work, who has actually studied bogus asbestos claims?
Why were so many relevant articles left out? Why was the Gitlin study ignored (results known well before ATS publication deadline)?
Why was there no acknowledgment of Professor Brickman's legal research on asbestos screenings?
Why was there no explanation of the change in profusion threshold from 1/1 [1986] to 1/0 [2004]?
Why was there no acknowledgement of the dichotomy between the 600,000+ benign asbestos disease diagnoses made by plaintiff-attorney-hired physicians, and the real world experience of practicing pulmonologists?
How did the ATS allow just a few heavily-biased physicians to co-opt the organization on this contentious issue? What AJRCCM published is not just an editorial, not just a personal statement by a few biased doctors, but came out as THE OFFICIAL ATS STATEMENT. How was this allowed to happen?
Posted December 20, 2004; Updated January 1 & February 14, 2005