Science-Based Medicine

EDITOR’S NOTICE: NOTE THE DISCLAIMER.

On “wholistic” medicine

If there’s one aspect of so-called “alternative medicine” and “complementary and alternative medicine” (CAM) is that its practitioners tout as being a huge advantage over what they often refer to sneeringly as “conventional” or “scientific” medicine is that — or so its practitioners claim — alt-med treats the “whole patient,” that it’s “wholistic” in a way that the evil reductionist “Western” science-based medicine can’t be. Supposedly, we reductionistic, unimaginative physicians only focus on disease and ignore the “whole patient.” Of course, to me this claim is belied by the hectoring to which my own primary care physician has subjected me about my horrible diet and lack of exercise on pretty much every visit I’ve had with her, but then maybe she’s an anomaly, along with Dr. Lipson on this very blog and pretty much every other primary care doctor I’ve ever dealt with. Anecdotal experience, I know, but since alt-med mavens appear to value anecdotal evidence above pretty much all else I thought it appropriate to mention here. Also belying the claim of alt-med practitioners that they “individualize” treatments to their patients in a way that science-based medicine does not is the maddening tendency of various alt-med modalities to settle on just One True Cause of All Disease, be it liver flukes as the One True Cause of Cancer, heavy metal toxicity as the One True Cause of cancer, autism, and various other diseases, or “allergies,” acid, or obstruction of the flow of qi as the One True Cause of All Disease.

Given the claim of “wholism” that is such an advertising gimmick among many of the varieties of woo, I’m always interested when I see evidence that alt-med is imitating its envied and disliked reductionistic competition. True, this is nothing new, given how alt-med has tried to seek legitimacy by taking on the mantle of science-based medicine wherever it can. Examples include the National Center for Complementary and Alternative Medicine (NCCAM), various organizations that try to confer legitimacy to pseudoscience by providing “certification” in various flavors of woo, and moves to push state medical boards to go further than that and confer legally protected status to practitioners by actually licensing them. This latter tactic has been very successful in that many states now license acupuncturists, while some states even license naturopaths and “homeopathic physicians,” the latter of which I find quite amusing because the term perfectly encapsulates what must remain of such a physician’s medical training after being diluted to 30C with woo. The only difference is that, unlike what is claimed with homeopathy, diluting MD medical knowledge with woo does not make it stronger. In terms of naturopathy, though, one of the most alarming aspects of the infiltration of naturopaths into the health care system is that some states in the U.S. and provinces in Canada are seriously considering allowing them to prescribe real pharmaceutical medications, even though they lack the training and knowledge to use such drugs safely.

Imagine my combination of bemusement and alarm, then, when I learned of a new specialty of pseudoscience, namely the field of naturopathic oncology.

Be afraid. Be very afraid. (I know I was when I first encountered this specialty.)
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Functional Medicine – What is it?

After extensive searching and examination, my answer is still – only the originators of “FM” know. Or, at least one must assume they know, because so far as I can see, I certainly see nothing that distinguishes “FM” from other descriptions of sectarian and “complementary/Alternative Medicine/” practices. A difference may lie in the advocates’ assumptions to have found some “imbalance” of body chemistry or physiology before applying one or more unproved methods or substances. From what I could determine, the “imbalance” or dysfunction is usually either imaginary or at least presumptive. And the general principles are so poorly defined as to allow practioners vast leeway to apply a host of unproven methods.

I figured there would be several ways to find out. One would be to read FM’s material – mainly what “they” placed on the Internet. Another would be to enter the system and find out as a patient or as a prospective practitioner what it is that “FM” claims to be. The third would be to listen to a practitioner or advocate on tape, disk, radio, etc.
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As a physician and scientists who’s dedicated his life to the application of science to the development of better medical treatments, I’ve often wondered how formerly admired scientists and physicians fall into pseudoscience or even generate into out-and-out cranks. Examples are numerous and depressing to contemplate. For example, there’s Linus Pauling, a highly respected chemist and Nobel Laureate, who in his later years became convinced that high dose vitamin C could cure cancer. Indeed, Pauling’s belief that high dose vitamin C could cure the common cold and cancer fueled the development of a whole new form of quackery known as “orthomolecular medicine,” whose entire philosophy seems to be based on the concept that if some vitamins are good more must be better. In essence, “orthomolecular medicine” is a parody of nutritional science; indeed, its advocates take credit for how some strains of “complementary and alternative medicine” (CAM) so frequently advocate the ingestion of huge amounts of dietary “supplements.” I could even go farther and say that orthomolecular medicine is clearly a major part of the “intellectual” (and I do use that term loosely) underpinning of the various biomedical treatments for autism that Jenny McCarthy and Generation Rescue advcoate.

There are other examples as well, all just as depressing to contemplate. For example, consider Peter Duesberg, a brilliant virologist who in the 1980s was widely believed to be on track for a Nobel Prize; that is, until he became fixated on the idea that HIV does not cause AIDS. True, lately he’s been trying to resurrect his scientific reputation with his interesting and possibly even promising chromosomal aneuploidy hypothesis of cancer, but, alas, true to form he’s been doing it by acting like a crank. Specifically, he sees his hypothesis as The One True Cause of Cancer and disparages conventional thinking as having been so very, very wrong all these years (with his being, of course, so very, very brilliant that he saw what no one else could see). Then there are people like Dr. Lorraine Day, who was a respected academic orthopedic surgeon in the 1980s. In the late 1980s, she started to flirt with AIDS pseudoscience through a scare campaign about catching AIDS from aerosolized blood. Of course, given the mystery and fear over HIV in the early years of the epidemic, such a fear, although overblown, was not so far out of the mainstream as to be worthy of the appellation crank. However, after being diagnosed with breast cancer, unfortunately Dr. Day rapidly degenerated into a purveyor of rank pseudoscience, as well as a New World Order conspiracy theorist, religious loon, and Holocaust denier. And let’s not forget Mark Geier, who, although not a distinguished scientist, did, before his conversion to antivaccinationism, apparently do a real fellowship at the NIH and appeared to be on track to a respectable, maybe even impressive, career as an academic physician. Now he’s doing “research” in his basement, injecting autistic children with a powerful anti-sex hormone drug and abusing epidemiology. There are innumerable other examples.
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One of the consistent themes of SBM since its very inception has been that, when it comes to determining the efficacy (or lack thereof) of any particular medicince, therapy, or interventions, anecdotes are inherently unreliable. Steve Novella explained why quite well early in the history of this blog, and I myself described why otherwise intelligent people can be so prone to being misled by personal experience and anecdotal evidence. Unfortunately, as I have also demonstrated, it’s not just patients who can allow themselves to be misled by anecdotes, but certain physicians who do not understand the scientific method but in their hubris think that their “personal clinical experience” trumps science, clinical trials, and epidemiology.

None of this is to say that there aren’t frequent instances when applying data from population-based studies to individual patients is problematic. It can indeed be. However, it often goes beyond that, and, indeed, if there is one defining characteristic of a quack that I’ve never failed to find when looking at individual cases, it’s a belief that he is able to identify when a treatment works based on his own personal experience and anecdotes. Unfortunately, it’s not just quacks who sometimes fall prey to this, because humans are cognitively wired to infer causation from correlation. This tendency, which was no doubt adaptive early in our evolution, simply doesn’t work well when it is applied to medicine and science. Without a doubt, it is the key driver, for example, behind the widely believed myth that vaccines somehow cause autism and that chelation therapy and other biomedical quackery can “cure” autism, a view popularized most recently by the very popular but very ignorant Jenny McCarthy in the U.S. and before that by the outright dishonest Andrew Wakefield in the U.K.

One of the other reasons why testimonials for quackery seem convincing is because most people simply do not know enough about disease, be it my specialty (cancer) or any other disease, how it is treated, and what its natural course can be expected to be. That is why, when I came across an example of just such a testimonial, specifically a breast cancer testimonial, I saw what is known as a “teachable moment. This teachable moment occurred on the very popular science blog Pharyngula, written by the ever sarcastic biology professor from Minnesota, P.Z. Myers. It actually surprised me in that the usual topics on Pharyngula include evolution, biology, the pseudoscience known as “intelligent design” creationism, politics, and atheism. P.Z. doesn’t usually dabble much in the realm of medical quackery, but my guess is that he was attracted to this particular piece of pseudoscience because of the religious angle.

Specifically, the quackery under consideration is known as God’s Answer to Cancer (GAC). Basically, it looks a lot like any number of quack electronic devices that promise to cure cancer; examples include Bill Nelson’s Electro Physiological Feedback Xrroid (EPFX) machine (1, 2, 3), Hulda Clark’s parasite zapper, or Alan Back’s Advanced Bio-photon Analyzer. All of these devices promise, in essence, to use low level electrical energy to “boost the immune system” and “replenish your life energy” plus or minus an additional promise to “zap parasites” (Hulda Clark’s unique spin on these devices, in which she claims that all cancer, AIDS, and most other diseases are due to a liver fluke, which her device supposedly “zaps.” Like these devices, the maker of GAC promises vague “immune system boosts,” but with the added twist that he claims that all disease is due to original sin (along, apparently, with the conventional alt-med “toxins,” diminished qi, and uncharacterized immune dysfunction). Amusingly, the Monsignor who created this device also disses Hulda Clark and advocates the use of laetrile and Linus Pauling’s orthomolecular medicine. The main difference is that he claims to have received the design for the device from God through a dream.
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This is almost the final entry (for now) in a series of posts about the pitfalls of regulating physicians who peddle quackery.† In previous entries we’ve seen how quacks have portrayed an illegal and pseudoscientific treatment, intravenous hydrogen peroxide, as legitimate; how a physician who practiced that and other dubious methods eluded definitive regulatory sanctions for years; examples of quacks banding together to form pseudomedical pseudoprofessional organizations (PPOs) and bogus board-certification schemes to establish the appearance of professional legitimacy, for protection from regulatory scrutiny, to garner political clout, to attract funds from interested businesses, to dupe the Accreditation Council for Continuing Medical Education into granting continuing medical education credits (CMEs) for pseudoscientific conferences, and more.

Now we’ll look at several examples of how state medical boards in the U.S. have abdicated their responsibility to protect the public from such practitioners. A few caveats: first, in most cases I can only guess why that has happened. Some of it has probably been due to naiveté, or to political or legal pressures. To some extent it has probably been due to faddism and its close relative, misleading language. Next, the examples given here are by no means exhaustive. Next, a state medical board can only be as effective as the language in the state’s medical practice act allows it to be, and that is determined by legislators (politics), not board members. Finally, state medical boards have not uniformly made the wrong choices regarding quack practices and practitioners.

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New Kid on the Block

Well, I’m not sure how new, but it was to me 6 months ago when I heard about Functional Medicine (FM) on a doc call-in program originating in Santa Cruz, Calif. The doc often presents a plurality of approaches to the callers’ problems, most of whom call because they seek self-help methods, supplements, or other short-cuts to help, or who share the utopian dream/meme of sectarian health claims through rearranging implausible ideas on the deck of the good ship Nature. (There could be a mixed metaphor in there somewhere but I go on…)

The radio call-in host, a middle-age sounding woman with a holistically oriented practice in a nearby town seems quite intelligent, grounded in real physiology, biochemistry, and mechanics of the body. I sometimes can catch her in errors but not as often as one could a more typical quacky doc, such as a chelationist. What I can hear is an intermittent string of recommendations I had never heard of, or sometimes had heard of and known to be false.  The program beams to a wide area – from Santa Cruz/San Jose area to the central coast in San Luis Obispo. It broadcasts on KUSP FM Saturday mornings at 9 AM Pacific time for those who want to listen on the net (Ask Dr. Dawn.)

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THE ZOMBIE RISES AGAIN

Vitamin C as a treatment for cancer is back in the news again.

I’m not surprised. This is one therapy favored by advocates of “alternative” medicine that keeps popping up periodically (seemingly every couple of years or so). This latest bit of news has turned up almost right on time after the last time there was a push for rehabilitating vitamin C as a cancer cure a couple of years ago. Back in the spring of 2006, there were two studies published (more on them later) which were touted by the “complementary and alternative medicine” (CAM) crowd as evidence that Linus Pauling was supposedly vindicated. A little less than two weeks ago, an animal study was published suggesting that high dose intravenous vitamin C had antitumor activity in mouse models. A couple of weeks prior, there had also been published a phase I clinical trial that showed that megadoses of IV ascorbate were safe and well-tolerated in cancer patients if they were appropriately screened for renal disease. Given the latest studies of this particular modality against cancer, it seemed like an opportune time for me to examine this new evidence and ask the question: Has Linus Pauling been vindicated?

I’ll cut to the chase. The short answer is: Not really, with the qualification that it depends on what you mean by “vindicated.” The long answer follows.
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I’ll start with a confession. I used to do something irrational. I used to take a daily multivitamin, not because I thought there was good scientific evidence to support the practice, but for psychotherapy. I tried to eat a healthy diet and worried about it. By taking a pill, I could stop worrying.

Then I found out that higher intake of vitamin A was associated with an increased risk of hip fractures in postmenopausal women like me, and I stopped. (High doses of vitamin A also cause births defects and are contraindicated in pregnancy.) Now I only take supplemental calcium and vitamin D, not on general principles but because of personal risk factors.

We’re being bombarded by advice to take vitamins and various other supplements. Health gurus like Andrew Weil recommend that everyone take vitamins (which they just happen to sell). The orthomolecular followers of Linus Pauling want us to take megadoses of vitamins. Ray Kurzweil tells us we should take vitamins to make us live longer; he takes 250 vitamin and supplement pills a day and thinks he will live forever. (You can read about his ideas in his book Fantastic Voyage: Live Long Enough to Live Forever.) Who should we believe? Continue Reading »

Why would medical schools risk association with quackery?

…a question from a Washington Post reporter in 1998.

The following hypothetical answer composed in response was never sent. It awaited a proper forum. Could this be one?

Well, Jeff, quackery is a pejorative term. Some time ago we recognized that words raise emotions and mental pictures. We recognized the cognitive dissonance raised by them, so we tried to eliminate quackery. We recognized the cognitive dissonance raised when one discusses acupuncture, chiropractic, homeopathy, and healing at a distance as if they were quackery when we made claims. For a century, most people just could not allow for the possibility that these things really work.

So over time we recognized that we had to do something about our language. That would be the first step in enabling the thought revolution that is upon us, and changing the paradigm in medicine and science. We simply changed the adjectives, and gave alternate names to the methods, added a few phrases to eliminate negative reactions, and shifted the negative terms to descriptions of the Medical Establishment (and, note the caps in that one.)
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