When Lab Research Scientists Play Doctors -The Knoepfler Files

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Do you remember that famous 1970s TV quote, “I’m not a doctor, but I play one on TV”? Well, that’s what some research scientists are doing. Let’s dig into that today.

Ph.D. vs. M.D.

A Ph.D. is someone who begins with a Bachelors in Science degree and then takes additional graduate-level course work in their field. Ultimately, on the lab research side, they work in a lab and then perform original research and rigorously defend a thesis, which can take years. An M.D. (or D.O.) is someone who went to medical school, and then a hospital internship, years of residency training in a hospital, and often subspeciality training. There are boards to sit for, licensing tests to take, and finally, after you’ve given away your 20s, you’re finally a practicing physician.

Hence, what do Ph.D.’s know about medicine? Not much outside of their very specific fields. Meaning if a lab Ph.D. tried to treat a patient or provide advice to a patient, that could be practicing medicine without training or a license.

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Paul Knoepfler

I’ve blogged before on Paul Knoepfler. On the one hand, Paul’s been instrumental in working toward ending predatory stem cell clinic practices. That began with good stuff, like opposing the crazy wild west of stem cells with clinics offering to treat desperate patients with serious incurable diseases. However, recently, Paul has stepped across a line that makes little sense.

That bright line that Knoepfler has crossed is defined by fellow academics. Meaning, once academic physicians begin to offer biologic therapies to their patients, the research is good enough to meet their definition of “best available evidence”. Hence it means that these biologics are now moving from the bench science stage into the clinical translation stage.

For example, recently Knoepfler was called out for attacking fellow academics like Joanne Kurtzburg. Joanne is a Duke professor and an actual medical doctor in hematology/oncology. She’s been engaged in pioneering work in collecting trial and real-world evidence in how umbilical cord blood may help autism. The good news is that Joanne’s work has shown that certain subgroups of this patient population may benefit from this therapy. You would think that would be a great thing. However, it’s earned Joanne stark criticism from Paul Knoepfler’s blog “The Niche”. Why? I’ve blogged on this issue. Paul and some colleagues know that by Joanne moving these cellular therapies into mainstream medicine, there will be less and less basic science grant funding. It’s just that simple.

Paul has often done the same with academics offering orthobiologics and seems to have little knowledge of the actual clinical research data available on these therapies. For example, he often attacks anyone using PRP, an orthobiologic therapy with dozens of randomized controlled trials supporting its use.

The False Dichotomy Factory

Paul Knoepfler is NOT A MEDICAL DOCTOR but has a Ph.D. As a result, his favorite narrative is to spin a false dichotomy that medicine is either proven or unproven. That’s a logical fallacy because there is a third option that’s in more widespread use by real medical doctors and that’s called Best Available Evidence (BAE). You see, we real doctors are often faced with patients who have conditions and treatment options that aren’t well researched. This dilemma is made more difficult by the fact that existing clinical trials narrow down the participants to a very select group of patients who are more likely to respond. Hence, more often than not, the patient asking you to help isn’t represented by a clinical trial. Joanne’s answer and that of countless academic physicians and private practitioners is to offer these patients a choice of doing nothing or doing something that may work. Again, these physicians make those decisions by looking at the best available evidence.

Playing Doctor

A colleague recently sent me this Q and A from Paul’s blog. Paul represents that this is a reader’s question:

“I went to Regenexx for joint pain, felt somewhat better for a couple of months, but now I’m back to square one. Is this typical and what should I do now? Go again?

Regenexx has become a well-known brand name in the clinic world, but I’m not convinced it gives a real lasting benefit over placebo. I did a review of Regenexx in October so check that out. I’m fairly skeptical because of a lack of strong, relevant, and long-term clinical data.

My impression is that what you’ve experienced with a transient perceived benefit is not that unusual. If the cells or PRP offered by one of the many Regenexx clinics do help people I believe it is mostly a temporary, anti-inflammatory kind of effect, which I’m not convinced is worth it. Getting many injections from such clinics boosts costs greatly and likely increases potential risks too. As to what to do now, I’d recommend talking to your regular doctor to get their advice.”

Let’s dissect what Dr. Knoepfler should have done here, if he was actually a medical doctor, rather than playing one on TV:

  1. What type of therapy did this patient receive? PRP, BMC, something else? Regenexx uses PRP in joints more often than anything else.
  2. Where was this injected? Knee, shoulder, hands?
  3. What structures were injected in that joint?
  4. What was the patient’s presenting diagnosis?
  5. Regenexx has always published its success and failure rates, is this a treatment failure?
  6. What comorbidities did the patient have?
  7. What is the severity of this condition?
  8. Did the patient follow medical advice?

As you can see, there’s a difference here between a Ph.D. who doesn’t know what he doesn’t know and an actual licensed medical provider.

Let’s take Knoepfler’s comments on PRP having a placebo effect. There are dozens of randomized controlled trials, many against placebo which are double-blinded (1-18). That means that the placebo effect that Paul is discussing has been convincingly ruled out by actual medical scientists.

However, there’s a much bigger issue here. Why would Knoepfler field a patient question in the first place? He seems to be providing actual medical advice here in discussing what he believes are the mechanisms of action for a therapy he has not identified (was this PRP or BMC?). Meaning, the patient may act on this advice and not see their family doctor, as Paul recommends. That action could impact the patient’s medical condition. Is this legal?

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Can a Ph.D. Give Medical Advice?

How many Ph.D.’s out there involved in this academic war between bench scientists and physicians are giving medical advice to patients? I would venture to guess that the smart ones know that any engagement with these patients is crossing a dangerous line. However, I would bet that a few, like Knoepfler, do cross that line, not based on a knowledge of the patient’s medical condition and the published best available medical evidence as a physician would, but based on an emotional response around protecting grant funding for their labs.

The upshot? Being a real doctor comes with immense responsibilities. It also comes with sleepless nights as you feel the weight of your medical decisions and the impact they have on real people. However, there’s a reason the statement, “I’m not a doctor, but I play one on TV” became popular. It’s fun to play a doctor and have none of the responsibilities that physicians bear. However, crossing that line between fake doctors and real doctors is a bit too far, even for “Dr.” Knoepfler.

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References:

(1) Cook CS, Smith PA. Clinical Update: Why PRP Should Be Your First Choice for Injection Therapy in Treating Osteoarthritis of the Knee. Curr Rev Musculoskelet Med. 2018;11(4):583–592. doi:10.1007/s12178-018-9524-x

(2) Uslu Güvendi E, Aşkin A, Güvendi G, Koçyiğit H. Comparison of Efficiency Between Corticosteroid and Platelet Rich Plasma Injection Therapies in Patients With Knee Osteoarthritis. Arch Rheumatol. 2017;33(3):273–281. Published 2017 Nov 2. doi: 10.5606/ArchRheumatol.2018.6608

(3) Tavassoli M, Janmohammadi N, Hosseini A, Khafri S, Esmaeilnejad-Ganji SM. Single- and double-dose of platelet-rich plasma versus hyaluronic acid for treatment of knee osteoarthritis: A randomized controlled trial. World J Orthop. 2019;10(9):310–326. Published 2019 Sep 18. doi: 10.5312/wjo.v10.i9.310

(4) Joshi Jubert N, Rodríguez L, Reverté-Vinaixa MM, Navarro A. Platelet-Rich Plasma Injections for Advanced Knee Osteoarthritis: A Prospective, Randomized, Double-Blinded Clinical Trial. Orthop J Sports Med. 2017;5(2):2325967116689386. Published 2017 Feb 13. doi: 10.1177/2325967116689386

(5) Raeissadat SA, Rayegani SM, Hassanabadi H, et al. Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial). Clin Med Insights Arthritis Musculoskelet Disord. 2015;8:1–8. Published 2015 Jan 7. doi: 10.4137/CMAMD.S17894

(6) Montañez-Heredia E, Irízar S, Huertas PJ, et al. Intra-Articular Injections of Platelet-Rich Plasma versus Hyaluronic Acid in the Treatment of Osteoarthritic Knee Pain: A Randomized Clinical Trial in the Context of the Spanish National Health Care System. Int J Mol Sci. 2016;17(7):1064. Published 2016 Jul 2. doi: 10.3390/ijms17071064

(7) Görmeli G, Görmeli CA, Ataoglu B, Çolak C, Aslantürk O, Ertem K. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc. 2017 Mar;25(3):958-965. doi: 10.1007/s00167-015-3705-6.

(8) Lana JF, Weglein A, Sampson SE, et al. Randomized controlled trial comparing hyaluronic acid, platelet-rich plasma and the combination of both in the treatment of mild and moderate osteoarthritis of the knee. J Stem Cells Regen Med. 2016;12(2):69–78. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5227106/

(9) Tavassoli M, Janmohammadi N, Hosseini A, Khafri S, Esmaeilnejad-Ganji SM. Single- and double-dose of platelet-rich plasma versus hyaluronic acid for treatment of knee osteoarthritis: A randomized controlled trial. World J Orthop. 2019;10(9):310–326. Published 2019 Sep 18. doi: 10.5312/wjo.v10.i9.310

(10) Lin KY, Yang CC, Hsu CJ, Yeh ML, Renn JH. Intra-articular Injection of Platelet-Rich Plasma Is Superior to Hyaluronic Acid or Saline Solution in the Treatment of Mild to Moderate Knee Osteoarthritis: A Randomized, Double-Blind, Triple-Parallel, Placebo-Controlled Clinical Trial. Arthroscopy. 2019 Jan;35(1):106-117. doi: 10.1016/j.arthro.2018.06.035.

(11) Huang Y, Liu X, Xu X, Liu J. Intra-articular injections of platelet-rich plasma, hyaluronic acid or corticosteroids for knee osteoarthritis : A prospective randomized controlled study. Orthopade. 2019 Mar;48(3):239-247. doi: 10.1007/s00132-018-03659-5.

(12) Di Martino A, Di Matteo B, Papio T, Tentoni F, Selleri F, Cenacchi A, Kon E, Filardo G. Platelet-Rich Plasma Versus Hyaluronic Acid Injections for the Treatment of Knee Osteoarthritis: Results at 5 Years of a Double-Blind, Randomized Controlled Trial. Am J Sports Med. 2019 Feb;47(2):347-354. doi: 10.1177/0363546518814532.

(13) Yu W, Xu P, Huang G, Liu L. Clinical therapy of hyaluronic acid combined with platelet-rich plasma for the treatment of knee osteoarthritis. Exp Ther Med. 2018;16(3):2119–2125. doi: 10.3892/etm.2018.6412

(14) Buendía-López D, Medina-Quirós M, Fernández-Villacañas Marín MÁ. Clinical and radiographic comparison of a single LP-PRP injection, a single hyaluronic acid injection and daily NSAID administration with a 52-week follow-up: a randomized controlled trial. J Orthop Traumatol. 2018;19(1):3. Published 2018 Aug 20. doi: 10.1186/s10195-018-0501-3

(15) Su K, Bai Y, Wang J, Zhang H, Liu H, Ma S. Comparison of hyaluronic acid and PRP intra-articular injection with combined intra-articular and intraosseous PRP injections to treat patients with knee osteoarthritis. Clin Rheumatol. 2018 May;37(5):1341-1350. doi: 10.1007/s10067-018-3985-6.

(16) Louis ML, Magalon J, Jouve E, Bornet CE, Mattei JC, Chagnaud C, Rochwerger A, Veran J3, Sabatier F. Growth Factors Levels Determine Efficacy of Platelets Rich Plasma Injection in Knee Osteoarthritis: A Randomized Double Blind Noninferiority Trial Compared With Viscosupplementation. Arthroscopy. 2018 May;34(5):1530-1540.e2. doi: 10.1016/j.arthro.2017.11.035.

(17) Lisi C, Perotti C, Scudeller L, Sammarchi L, Dametti F, Musella V, Di Natali G. Treatment of knee osteoarthritis: platelet-derived growth factors vs. hyaluronic acid. A randomized controlled trial. Clin Rehabil. 2018 Mar;32(3):330-339. doi: 10.1177/0269215517724193

(18) Cole BJ, Karas V, Hussey K, Pilz K, Fortier LA. Hyaluronic Acid Versus Platelet-Rich Plasma: A Prospective, Double-Blind Randomized Controlled Trial Comparing Clinical Outcomes and Effects on Intra-articular Biology for the Treatment of Knee Osteoarthritis. Am J Sports Med. 2017 Feb;45(2):339-346. doi: 10.1177/0363546516665809.

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile

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