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The false dilemma of David Katz: Abandon patients or abandon science

Dr. David L. Katz is apparently unhappy with me. You remember Dr. Katz, don’t you? If you don’t, I’ll remind you momentarily. If you do, you won’t be surprised. Let me explain a bit first how Dr. Katz recently became aware of me again.

Last week, I posted a short (for me) piece about something that disturbed both Steve Novella and myself, namely Traditional Chinese herbalism at the Cleveland Clinic? What happened to science-based medicine? Steve had blogged about it as well a couple of days earlier. In actuality, it was a post that had originally appeared at my not-so-super-secret other blog, and, in my characteristically slightly arrogant way, I thought it was good enough that it deserved to be showcased here at Science-Based Medicine. To my surprise, Maithri Vengala over at The Healthcare Blog noticed and asked me if I would mind letting her post it over there. Never being one to turn down a request to showcase my work to a wider (or at least different) audience, I gave her my permission. The result was that my post ended up being published here, and I thought nothing more of it.

Until yesterday, that is.

Yesterday, thanks to the magic of Google Alerts, I became aware that Dr. David Katz was very unhappy with my post. At the very least, he strongly disagreed with it, so much so that he felt the need to respond. Naturally, he chose as his venue The Huffington Post, which is well known as a bastion of quackery, antivaccine pseudoscience, and Deepak Chopra-inspired magical thinking, to respond. Indeed, so bad is HuffPo (as it’s “nicknamed”) that Steve Novella and I have both referred to it as waging a “war on medical science,” and HuffPo has been a frequent topic of discussion on this very blog for its abysmal record of publishing pseudoscience, a record that goes back to its very beginning in 2005, when antivaccinationists flocked to the fledgling blog and news site. And that doesn’t even count all the nonsense from Deepak Chopra and even promotion of outright cancer quackery.

The title of Dr. Katz’s response is very telling: A Holistic View of Evidence-Based Medicine: of Horse, Cart and Whip. Yes, it’s a rather odd metaphor. Dr. Katz’s apparent viewpoint is that that integrative medicine is the bees’ knees, the “best of both worlds,” and that stodgy old physicians like myself who insist on science are just being closed minded. Wait, that’s actually not quite what he said. I’m sorry, but I’m thinking of the old David Katz, whom I’ll describe in a moment. The new, improved David Katz is completely about the evidence, so much so that he trumpets his credentials thusly at the beginning of his article:

First, I am a card-carrying member (well, I would be if they issued cards) of the evidence-based medicine club. I am a conventionally trained Internist, and run a federally funded clinical research laboratory. I have taught biostatistics, evidence-based medicine, and clinical epidemiology to Yale medical students over a span of nearly a decade. I have authored a textbook on evidence-based medicine.

But on the other hand, I practice Integrative Medicine, and have done so for nearly 15 years. And I represent Yale on the steering committee of the Consortium of Academic Health Centers for Integrative Medicine.

That’s nice.

It is rather telling that Dr. Katz apparently seems to feel compelled to begin his rebuttal with, in essence, an appeal to authority—his. Look, he seems to be saying, I’m not one of those airy-fairy alternative medicine hippies like Andrew Weil who believes that natural is better. I’m a real scientist! I have federal funding! I’ve even taught biostatistics and written a book on evidence-based medicine (13 years ago). Respect me, dammit! Well, it’s true that Dr. Katz has many more publications than most of us do, and he does indeed run an federally-funded center, while I haven’t had NIH funding since 2011, thanks to the funding crunch at the NIH leading to increased competition that I haven’t (yet) been able to crack, but so what? It is the quality of evidence and argument that matters. That’s why I rarely dwell long (if I mention them much at all) on my own qualifications, even when I’m writing about topics that fall under the purview of my specialty that I might reasonable be considered to be an expert in, such as screening mammography. It’s just…unseemly.

There’s also the not-insignificant issue of how Dr. Katz basically begins his response by attacking what can only be described as a straw man whose size rivals that of one that might be seen at a Burning Man gathering. It apparently irks him mightily that I described one of the flaws in reasoning that herbalists frequently use to justify the use of herbal medicine over pharmaceutical medicine as believing that somehow “natural” is better, that the ingredients in herbs are “synergistic,” even though the evidence supporting such an assertion is incredibly unpersuasive, with less than a handful of known exceptions. Dr. Katz seems to think that that statement was aimed at him specifically. So vociferous is the umbrage that he takes at the suggestion that he objects to it multiple times in just his one post, beginning with this:

I did not go into Integrative Medicine because I believe “natural” is reliably better or safer than “scientific.” I respect the often considerable prowess of modern medical technology and pharmaceuticals. And, frankly, I have never much cared whether a therapy derived from a tree leaf, or a test tube. I have cared about whether it was safe, and whether it was effective.

Well, no one ever said that Dr. Katz went into integrative medicine for that reason, and I note that, in the context of my post, that criticism was leveled more at herbalists and supporters of using herbal medicine in CAM than anyone else. Yet, Dr. Katz seems to take the criticism very, very personally. It reminds me of the scene from The Godfather, when Michael Corleone first proposes killing Sollozzo and Captain McClusky (Sollozzo ordered a hit on Michael’s father Vito Corleone, who unexpectedly survived the attempt on his life, and McClusky beat Michael up when he foiled a second assassination attempt by Sollozzo’s men on Vito as he was in the hospital recovering from the serious wounds from the first assassination attempt), at which Michael’s brother Sonny laughs and tells him, “You’re taking this very personal. Tom, this is business, and this man is taking it very, very personal.” The only reason I can think of that Dr. Katz would react so self-righteously to criticism of herbal medicine is because he taking my criticism as personal as Michael Corleone did Sollozzo’s attempts to kill his father. He does, after all, apparently use herbal medicine while viewing himself as a Real Scientist and his pursuit of “integrative medicine” as being truly evidence-based. Unfortunately, he appears to be deluding himself, and his protestations carry a not-so-faint air of whistling past the graveyard.

Before I go on, I will, however, point out that I actually do agree with Dr. Katz on one point, and I’m sure that Steve and pretty much everyone else here at the SBM Blog also agree. We don’t care whether a treatment is “natural.” Nor do we much care whether a therapy is derived from a tree leaf or a test tube. Like Dr. Katz, we only care about whether it works and is safe. Again, the implication on Dr. Katz’s part by emphasizing that seems to be that somehow those of us who criticize “integrative medicine” care more about where a treatment came from than the evidence base behind it. We don’t. It was not from people like Dr. Katz that we got the maxim, oft-repeated in various forms by skeptics as diverse as Richard Dawkins and Tim Minchin, “There is no such thing as alternative medicine. There is medicine that has been scientifically proven to work and medicine that hasn’t. What do you call alternative medicine that’s been scientifically proven to work? Medicine.”

Dr. Katz also tries to convince his readers, using a typical favorite trope of supporters of “complementary and alternative medicine” (CAM) and integrative medicine, that evidence-based medicine (EBM) is not particularly evidence-based. I’ll give him credit that at least he didn’t cite the usual myth that only 15% of current medical practices are “evidence-based,” although he did cite the high end of these tropes, namely that only 50% of medical practices are evidence-based. As Bob Imrie discovered when he tried to track down the origin of that claim, the 15% figure comes from a small study in the north of England from 1961 that was looking at insurance reimbursement. Other, somewhat higher estimates (10-35%) appear to come from a chapter by Kerr L White entitled “Archie Cochrane’s legacy: an American perspective” in the book Non-random Reflections on Health Services Research: on the 25th anniversary of Archie Cochrane’s Effectiveness and Efficiency. In actuality, most estimates these days are considerably higher. Of course, it varies by specialty, but existing evidence suggests that around 76% of interventions are supported by at least some form of compelling evidence, be it randomized controlled trials (RCTs) or strong observational evidence. Indeed, as far back as 1995 we knew that for inpatient medicine, at least, over 50% of interventions were based on RCTs and that 82% of interventions were evidence-based.

Dr. Katz’s defense of integrative medicine, spurred by the criticism of the herbal medicine clinic over at the Cleveland Clinic, boils down to three points:

  1. Evidence is not a reliable differentiator of conventional and alternative medicine.
  2. To the extent that evidence does differentiate conventional and alternative medicine, it’s often because — in the pursuit of evidence — cart and horse routinely swap positions and money cracks the whip.
  3. Evidence is not black or white. It comes in shades of gray.

In other words, Katz uses arguments that consist, basically, of a tu quoque argument (your evidence based medicine has a lousy evidence base, too!); special pleading based on the claim that no one wants to fund studies of “integrative medicine” because no one can make money off of it; and one that argues against a straw man, namely the insinuation that defenders of SBM assume that evidence is cut and dried, black or white, yes or no, a claim that I’ve yet to see any of us make. (Maybe he is referring to the use of basic science principles to argue against homeopathy, which is about as close as we get to such proclamations.)

I’ve already mostly dealt with #1 by showing that the evidence base for EBM is far higher than Dr. Katz would like you to believe. I concede, it should be higher, but compared to anything in “integrative” medicine, it’s not even close, Dr. Katz’s citation of a paper of his from 11 years ago about “evidence mapping” notwithstanding. One notes that evidence mapping, as described in the paper by Dr. Katz and colleagues, doesn’t really show what he says it shows in that it doesn’t really demonstrate that there is high quality evidence for CAM that is equivalent (or even close to equivalent) to that which exists for EBM. In reality, the paper simply describes a method that might or might not have some validity. That’s all.

The second objection is nothing more than the oft-repeated whine from supporters of CAM and integrative medicine that their methods aren’t studied, that they’re given short shrift, because big pharma can’t make money off of them. A frequent variant of this particular line of special pleading is to impugn big pharma as being so hopelessly corrupt that one has to consider CAM and integrative medicine as potentially viable alternatives, often with a not-so-subtle insinuation that big pharma isn’t interested because there’s no money or even that big pharma is actively “suppressing” alternatives, the better to protect its profits. Whenever I see such an argument, I like to paraphrase Ben Goldacre’s adage that says something like:

Or:

Or:

Problems in medicine do not mean that homeopathic sugar pills work; just because there are problems with aircraft design, that doesn’t mean that magic carpets really fly.

In other words, just because there are problems with drug development and how big pharma handles drug trials does not mean that the pseudoscientific methods of CAM and integrative medicine “work.” Just because, as Dr. Katz demonstrates, a purified drug (coenzyme Q10) might be effective in preventing death from congestive heart failure and that the clinical trials that failed to find a benefit a decade ago were small, that doesn’t mean “integrative medicine” is valid, nor does it mean that herbalism works. Such claims are non sequiturs. In fact, I even challenge Dr. Katz as to why coenzyme Q10 should even be called “alternative” or “integrative” at all. If it works, it’s science-based medicine. To turn Dr. Katz’s words back on him, it doesn’t matter where it came from or if it’s natural. I would also argue that, since it is a purified chemical and that is taken like a drug, coenzyme Q10 as used for treating congestive heart failure should be considered a drug, just like beta blockers.

In any case, the answer to pharma is not to conclude that integrative medicine works, but to work on fixing the issues with pharma, publication of clinical trials, and funding of research, as Ben Goldacre is doing his part to do. In other words, if you agree that there is a problem with the distribution of research funds in this country, you don’t have to conclude that research into CAM remedies is being “suppressed” or ignored because pharma can’t make money off of them. The heart of Dr. Katz’s tortured metaphor seems to be that money is the “whip” that drives what is studied, leading to the reversal of cart and horse—or something. It is a rather incoherent metaphor. Dr. Katz’s odd metaphor aside, though, I’d say it’s quite the opposite if you look at it as a ratio of funding to promise (if it were possible to quantify promise). Given how wildly implausible many CAM treatments are (more on that later), the amount of money spent on them by NCCAM and other sources far outstrips any reasonable financial estimate of what positive research findings would be worth. Indeed, studying such remedies without compelling preclinical evidence really is putting the proverbial cart before the horse. Whether ideology (in the form of increasing acceptance of magical CAM thinking) or money from the National Center for Complementary and Alternative Medicine or Bravewell is the “whip” matters little. The cart has been put before the horse.

Dr. Katz’s third argument is a massive straw man, too:

Clinical decisions are easy if a treatment is known to be dangerous and ineffective, or known to be safe and uniquely effective. But what if a given patient has tried all the remedies best supported by randomized clinical trials, but has “stubbornly” refused to behave as the textbooks advise and failed to get better? Or what if a patient just can’t tolerate the treatments with the most underlying evidence? One option is to tell such a patient: See ya! But I think that is an abdication of the oaths we physicians took. When the going gets tough, we are most obligated to take our patients by the hand, not wave goodbye.

See what I mean? No one—and I mean no one—here argues for abandoning the patient who fails to get well when treated with science- and evidence-based treatments. Dr. Katz’s thinking is indeed muddied, as Kimball Atwood described so long ago. Indeed, if anyone is exhibiting black and white thinking here, it’s him. To him, if “conventional” science- and evidence-based medicine can’t help a patient, the choice is between abandoning the patient and embracing quackery. That’s a false dilemma in which Dr. Katz represents embracing quackery as the only other choice besides leaving the patient to his or her own devices. In fact, Dr. Katz even makes it more explicit here:

Integrative Medicine should not involve a choice between responsible use of evidence and responsiveness to the needs of all patients. It should combine the two. We should do the best we can with the evidence we have, but recognize that high quality evidence may start to dwindle before our patient’s symptoms start to resolve. We should resolve to confront this challenge with our patients, not leave them to fend for themselves.

Again, no one—and I mean no one—argues that EBM or SBM means choosing between the responsible use of evidence and responsiveness to the needs of patients. That is merely a convenient false dichotomy that Dr. Katz uses to justify embracing quackery to himself and to paint supporters of SBM as heartless bastards who care more about evidence than actual patients. Dr. Atwood had a good answer for such arguments, namely that a major role of the physician is as expert consultant and that morally we are obligated to provide recommendations that are rooted in evidence and science, not magic and superstition. In other words, we are obligated to tell the truth about the science behind the interventions we propose. Moreover, there are virtually no situations in which CAM or “integrative medicine” is the only option left, but Dr. Katz quite consciously portrays the choice thusly, as black or white, as CAM being the “only” choice after the failure of EBM for a patient. It is a gambit he has used many times before. Indeed, he portrays himself as having been “led to” integrative medicine” by this dilemma, while portraying himself as totally dedicated to science, an odd proclamation, given some of his previous statements.

Perhaps the most famous of these occurred a few years ago, resulting in a quote that caught a lot of people’s attention, including mine:

I think we have to look beyond the results of RCTs in order to address patient needs today, and to do that I’ve arrived at the concept of a more fluid form of evidence than many of us have imbibed from our medical educations…[Referring to a patient anecdote, Dr. Katz went on.] Now, we don’t want you on narcotics anymore than you want to be on narcotics. We initiated a course of acupuncture and over the next two to three months weaned him off narcotics. He was pain-free on acupuncture and subsequently transitioned into homeopathy. Now, I don’t care to get into a discussion of how or even whether homeopathy even works, but this guy had tried everything.

[...]

And the anecdotal evidence that homeopathy might be effective was brought up by the naturopaths. We tried it. It worked.

Of course, Dr. Katz neglected to describe exactly how he knew his intervention of acupuncture and homeopathy had “worked,” namely anecdotal evidence which, as we have seen many times in this blog, is incredibly prone to misinterpretation through regression to the mean and confusing correlation with causation, thanks to a number of cognitive quirks we humans all share. Indeed, science itself, not just science-based medicine is designed to minimize the effects of these quirks. In response to criticism, Dr. Katz went even further:

The view I expressed, and that guides our practice, is that human need goes on long after the results of randomized clinical trials start to run thin. I do not think doctor and patient should part company there. I believe that responsible use of the science we have should not preclude responsiveness to the needs of patients that fail to respond as textbooks say they should to that all-too-limited science. I believe, in other words, that patient need, not trial results, should be the ultimate master medical care must serve.

I learned devotion to evidence-based practice from my teachers and professional colleagues; I was pushed toward integrative medicine by the needs of my patients.

This was from 2008. Dr. Katz has been using the same false dichotomy for nearly six years now, minimum, and certainly much longer. It’s also very much a postmodernist view, in which Dr. Katz views science as nothing more than another “narrative” that he can abandon when he perceives his patient’s need driving him to do so. These are subtle distortions of language that are very powerful and incredibly useful for CAM advocates. RCTs, “what we know,” and science are all conflated as though they mean the same thing, leading to a false dichotomy in which the only choice when the edges of what RCTs tell us are reached is to rely on anecdotes, testimonials, and other forms of unreliable and subjective “evidence” in order to justify choosing unscientific treatment modalities, even abject pseudoscience like homeopathy. It’s the dilemma at the heart of alternative medicine (and, make no mistake, “integrative medicine” is nothing more than “integrating” alternative medicine into science-based medicine).

Particularly contradictory is this assertion:

The array of potential options extends, of course, to herbal remedies and nutriceuticals as well — the apparent focus at the Cleveland Clinic. And, more controversially, it potentially extends to modalities that conventionally trained clinicians find implausible, such as homeopathy or energy therapies. I won’t get too deep into such weeds today, but have done so before.

The paper referenced is an amazing bit of woo. In it, Dr. Katz tries to argue that the implausibility argument (i.e., when we argue that modalities like energy medicine and homeopathy are implausible to the point of being, for all practical purposes, impossible on basic science grounds alone because they violate multiple well-established laws of physics and chemistry and the “energy” in energy medicine has never been detected) is not so persuasive. He begins by describing organisms as being made up of molecules, which are made up of atoms, which are made up of subatomic particles, and how all matter is mostly empty space, so that when two people shake hands they are not actually “touching” each other, although they perceive it that way. We are thus “electromagnetic.” (Sounds like quantum to me.) Using language and flourishes that wouldn’t be out of place in Neil deGrasse Tyson’s update of Cosmos (in fact, I recall a segment recently that said essentially the same thing about two human beings touching each other), Dr. Katz marvels at this, particularly how amazingly implausible it seems to him, and then turns science on its head to make a massive argument from that very wonder and seeming implausibility. After describing how “inexplicable” he finds our existence and consciousness to be, Dr. Katz then writes:

I would not deny the implausibility of the therapeutic influence from not touching, nor contest the improbability of healing messages left behind by molecules diluted out of solution. But once we acknowledge that little could be more unlikely or wondrously implausible than a handshake, the topic of plausibility must be broached with greater purpose. I don’t understand homeopathy, or believe in it per se. I find it inexplicable and farfetched, but perhaps slightly less so than the experience of a caress, and incalculably less so than our existence.

We are. Therefore, I think, we must be plausible. But frankly, I don’t see how.

That’s right. We exist and our existence is implausible to Dr. Katz; so homeopathy and energy medicine, as implausible as they are on the basis of science, maybe aren’t so implausible after all, at least not to Dr. Katz. And just when you think it can’t get more flaky than that, Dr. Katz drives the point home:

We live out our lives within the bounds of perception that are but a thin layer of what is. Well beneath it, where reality meets bedrock, solar systems, software, and sushi are the same. This goes well beyond lifting the lid from Pandora’s box; it blows open the walls of Descartes’ carton. It is an admission that you and I, the lid and the box, poet and page, myth and math, Pandora and Descartes are the same stuff, and there is nothing much to any of us.

I am writing, you are reading, and we are thinking—and therefore we ostensibly are. But that we are is a veritable assault on plausibility. What we think we are is merely what we perceive ourselves to be.

Therefore, homeopathy and energy medicine aren’t implausible, you nasty skeptics! Q.E.D. Oh, and we are all made of star-stuff, too; so homeopathy and energy medicine must work. That really is the heart of Dr. Katz’s argument against rejecting scientifically implausible/impossible contentions. It’s just that bad.

In the end, Dr. Katz sounds very frustrated and unhappy—and, yes, defensive. At one point in his post he complains that it was “painfully clear” to him that he “could not make everyone better” and “modern medicine couldn’t make everyone better.” And it’s true. Most of the conditions that internists routinely take care of are not curable, but that’s not a reason to embrace magical thinking, as Dr. Katz does. I also confess that it’s the reason I went into surgery rather than internal medicine. After originally planning to go into internal medicine, in medical school I found that, personality-wise, I wasn’t suited to managing chronic diseases with no cure, like diabetes, hypertension, heart disease, and the like, although I greatly admire the primary care docs who can do this well. I couldn’t; so I went into a specialty where cutting out a tumor is usually curative. In other words, in collaboration with medical and radiation oncologists, I am in the fortunate position of being able to make the vast majority of patients I see better. Personally, I wonder if Katz would have been happier and less attracted to quackademic medicine if he had chosen another specialty, one not so involved in taking care of chronic degenerative diseases as internal medicine.

Maybe he wouldn’t have come to the conclusion that the only way he can help patients whom he can’t cure is to abandon science in the guise of claiming to be scientific. It’s a false dilemma that drives too many physicians to abandon their critical thinking skills as well.

ADDENDUM: Steve Novella has also dissected Dr. Katz’s article.

Posted in: Critical Thinking, Energy Medicine, Herbs & Supplements, Traditional Chinese Medicine

Leave a Comment (184) ↓

184 thoughts on “The false dilemma of David Katz: Abandon patients or abandon science

  1. Lawrence says:

    Arguing that the fantastical nature of the Universe (as shown wonderfully in the new Cosmos series) suddenly makes “magical thinking” correct or at least plausible, goes completely against the premise of Cosmos in the first place – that rational, science-based thinking has allowed us to understand the physical attributes of the Universe and the physical laws that explain its behavior (and substance).

    He is instead, arguing for a return back to the days before real Scientific Thinking & just making stuff up as we go along (as long as we can “think” of some sort of plausible mechanism, no matter how physically implausible it actually is – like Homeopathy).

  2. Laurens says:

    I get the impression that in Europe the “only 15% of medical practices are evidence-based” claim is usually based on a complete misunderstanding of the BMJ’s Handbook of Clinical Evidence. This handbook (which is regretfully behind a paywall) has been in existence for about 15 years and contains information about the effectiveness of some 3.000 treatments as reported in (mostly) RCTs. The 2012 edition concluded that of these treatments:

    - 11% was beneficial;
    - 23% was likely to be beneficial;
    - 7% was a trade-off between benefits and harms;
    - 6% was unlikely to be beneficial;
    - 3% was likely to be ineffective or harmful;
    - 50% was of unknown effectiveness.

    Supporters of CAM frequently use these figures to claim that only 11% of conventional medicine is evidence-based, and even that the rest is quackery. Alternatively, they claim that only 11% of all regular medication is proven to be effective (they narrow “treatments” down to “medication”; but then again, these people believe that regular doctors take pleasure in prescribing antibiotics and other ‘poisons’ all day). However, they are missing a few important points:

    - The Handbook is not all about conventional medicine. In fact it also includes quite a few CAM-treatments, such as acupuncture for various conditions. Here’s what BMJ itself says:

    “‘Unknown effectiveness’ is perhaps a hard categorisation to explain. Included within it are many treatments that come under the description of complementary medicine (e.g., acupuncture for low back pain and echinacea for the common cold), but also many psychological, surgical, and medical interventions, such as CBT for depression in children, thermal balloon ablation for fibroids, and corticosteroids for wheezing in infants.”

    It is, of course, notoriously difficult to prove in an RCT whether surgically removing a person’s inflamed appendix is in fact ‘effective’ and therefore ‘evidence-based’. But no-one will doubt it is.

    - The Handbook is only about the treatments that are available. In fact, again BMJ explicitly states that:

    “our categorisation of the effectiveness of treatments does not identify how often evidence-based and non-evidence-based treatments are used in practise. We only highlight how evidence based treatments are for certain indications, based on randomised controlled trials.”

    If we look at how often evidence-based treatments are used in practice, we can agree with Ben Goldacre (Bad Science) that, depending on specialty, between 50 and 80% of all interventions are evidence-based. It could and should be higher, of course, and it probably would have been higher if we hadn’t been forced to use so much of our time fighting CAM-religion. Or if we had spent NCCAM and OCCAM’s budget for other research than studies exploring the effects of praying on brain tumors.

  3. Phil Koop says:

    I liked Tim Hartford’s analysis of the ethics of RCT’s here: http://timharford.com/2014/04/the-random-risks-of-randomised-trials/.

    In my opinion, he justifies his conclusion: “The world often surprises even the experts. When considering an intervention that might profoundly affect people’s lives, if there is one thing more unethical than running a randomised trial, it’s not running the trial.”

  4. Friendly Skeptic says:

    Great yet maddening piece. Among all of Dr. Katz’s nonsense, the hardest for me to believe is that any physician could actually think homeopathy is viable in any sense. I know I shouldn’t use a litmus test for anyone, but when I hear a health-care professional support homeopathy, it’s pretty much game over for me.

  5. Windriven says:

    “Dr. Katz’s citation of a paper of his from 11 years ago about “evidence mapping” notwithstanding.”

    Yes, published in that tome of righteousness, “Alternative Therapies in Health and Medicine.” From the abstract it appears that Katz’s “evidence mapping” might also be called CAM: Complementary and Alternative Meta-analysis. The article itself is behind a paywall (really, you’ve got to be effing kidding me) but it appears to be a nine step program. I wonder if the meetings start with something like: “My name is David and I’m a quack?”

    I wonder why it is that quacks don’t just man up with the evidence for their quackery? I wonder why there has to be a nine step program? Does F=ma or does it not? Is there robust evidence to support homeopathy or is there not? If there is, quit the smoke and mirrors nonsense and habeus up the corpus. If herbs and eye of newt zap pancreatic cancer, what is the agent that works the magic? If you can’t answer that then you can’t know the dosage because you can’t demonstrate the amount of the agent in any sample.

    You can put a quack in a lab coat, you can send him to medical school, you can hang papers on his wall, you can give him federal funds. But none of that makes him a scientist. There is a rigor to the thought and expression of a scientist that cannot be faked. There are no appeals to magic, no special pleadings for dispensation from the rules of evidence.

  6. Andrey Pavlov says:

    It seems that Dr. Katz is not only flirting with Deepakian nonsense, but also explicitly saying Bayesian statistics are utterly useless (since literally everything is so implausible that, to a first approximation, everything is equally plausible) and teetering on the edge of solipsism to boot. He is playing intellectually dishonest games with bar graphs – trying to get us to believe that everything is the same by scaling up the y-axis so high that all the data points on prior probability look like the same tiny dots down at the bottom, instead of scaling the units appropriately so we can see the vast differences between them. The old trick of talking about absolute risk instead of relative (or vice versa) when it suits your argument rather than to illustrate a valid point.

    The only thing that perturbs me more is that he teaches at Yale. Though I am getting less surprised by this. It is shocking how many people (who should know) don’t understand what a p-value is, what it can and cannot tell us, and use it like a cudgel to beat a paper into pretending to have meaning.

    1. Windriven says:

      “and use [p values] like a cudgel to beat a paper into pretending to have meaning.”

      Well said!

  7. As an internist who does deal with chronic disease management all day, I can understand the drive to offer patients ‘something’ when you are essentially out of real options. But then comes the issue of honesty.

    If a provider understands the meaning of blinded, randomized controlled trials, and those trials show that a given modality is no more effective than placebo, then the treatment does not work. This is definitional. To claim to the patient that you think it might work is dishonest or denialism of a concerning degree. The provider has to deal with the ethics of this.

    It seems the better approach is to be honest about what is known to work, what is not known to work, and what is known not to work. An honest discussion usually leads to a rewarding path for the patient and the provider.

  8. goodnightirene says:

    @Windriven and Andrey Pavlov

    Well done lads!

    It is amazing that Katz does not have the curiosity to ask a simple “why?” when a patient “feels better” from a CAM treatment.

    1. Andrey Pavlov says:

      @GNI:

      Danke! I have actually gone over to “The Healthcare Blog” and posted a reply to Dr. Katz. I’m curious to see his response. The last time I attempted something like this was at the NCCAM blog which garnered the attention of (former) Deputy Director Killen in which he essentially flounced off with a blog post that was nothing more than hand waving away my criticisms. The most memorable part is when he stated unequivocally that the NCCAM does not bother itself with defining “CAM”. Can you imagine if the National Cancer Institute did not bother itself with defining “cancer”?

      1. David Gorski says:

        Except that NCCAM does define CAM, to the point that it divides it into five categories. It’s very odd that Dr. Killen would claim that NCCAM doesn’t try to “define” CAM.

        1. Andrey Pavlov says:

          Sure, except that – as you know – those definitions are incredibly nebulous and useless. When I worked diligently to pin him down he came up with this post in which he said:

          While generally useful in describing attributes of health care, such definitions by exclusion pose challenges for NCCAM and the field of research we support. Among them are the plethora of potential research topics, vagaries about when or whether something is in or out of “the box,” and issues highlighted in my previous post on “Plausibility”.

          Frankly, we do not spend much time wrestling with questions about whether something is “specifically CAM.”

          It wasn’t in as quite as many words, but if the NCI didn’t spend much time wrestling with whether something is “specifically cancer” would that parse well?

        2. Carl says:

          A list of examples is not a definition.

        3. Andrey Pavlov says:

          Dr. Katz has replied

          1. Andrey Pavlov says:

            As did I, once more. Then he again, and I one more time.

            He is pulling the same shenanigans as Dr. Killen. I will reproduce the responses here in case that is easier for others rather than clicking over to THB.

            My first comment:

            Point #1 is nothing more than a tu quoque argument. Regardless of whether your statistics are actually correct (and they are arguably not) it has nothing to do with the question at hand. Whether “conventional medicine” is 100% evidence based or 0% evidence based does not endorse nor impugn so-called alternative medicine.
            Point #2 is valid but incomplete. Yes, undoubtedly patentability and profit drive pharmaceutical development. And this does include some perverse incentives. However, it is incorrect to say that natural products are unpatentable. Even CoQ10 products can be patented – either by brand name or by process of development. Tylenol is an excellent example – it is generic, yet the brand still exists and now IV acetaminophen is available and at extremely high cost. The key is that there was some actual evidence to support its use in control of post-surgical pain. All from a widely known generic drug that in and of itself is not patentable. So this argument falls flat.
            But the truly key piece that is missing in your understanding and analysis is by far the most important – what is the likelihood that it will work. Things that have billions of dollars invested in their development are not going to be utterly implausible like homeopathy or some random herbal decoction pulled from the thoughts of a pre-scientific thinker in ancient China. So yes, the profit motive does end up steering research away from some viable sources, but by in large it steers away from all the ones least likely to work. Yet also happen to be the ones you seem to favor.
            Additionally, your own example of CoQ10 undermines your argument. Something that is difficult to monetize is more likely to get short shrift, no doubt. But when it has some rationale and a little bit of evidence that it actually works it gets researched. Otherwise you wouldn’t have the example to tell us. You’ve given not an example to support your argument, but one to show that even with the known flaws of the system it still does work (though it can always work better and we should strive to improve at all times).
            And point #3 is a straw man. One intended to obfuscate the point and try to argue that because clinical medicine is hard and sometimes confusing, anything goes. There is more to evidence than just RCTs, so when our available treatments fail our patients the answer is not to resort to magical thinking and throwing stuff at the wall until it sticks, but to actually use the other available evidence at our disposal. Doing so would make the idea of offering a patient homeopathic nostrums not just silly but downright unethical. Sticking your fingers in your ears and claiming that you just don’t know how it works but it does is not a professional nor rational way to approach patient care. There are reasons why homeopathy cannot be anything more than a placebo so well verified that to think otherwise shows a profoundly disturbing level of ignorance, whether willful or not.
            Ultimately your entire argument boils down to the idea that when the limits of modern medicine have been reached, magical thinking and randomly picking therapies out of a giant grab bag are not just reasonable but the only alternatives, dressed up in the guise of patient centered care. Both of these ideas are patently false. And patient centered care is independent of the question of the evidence base for therapeutic approaches.
            We can do much better for our patients than treating them like children and pretending magical nostrums and incantations do something for them. Doing as you suggest is nothing more than the overbearing paternalism of our forebears and has no place in truly patient centered care.

            His reply:

            We disagree on a number of points, clearly- but I will only address one. The difference between, for instance, co Q10 as “alternative” medicine and co Q10 as “conventional” medicine is measured in years, if not decades. Yes, the research in this case did eventually get done- but it was ten years after under-powered studies were used to declare the ‘co Q10 for heart failure hypothesis’ dead. Does that happen with a conventional drug: it is studied in too small a sample, little is seen, and the ‘hypothesis’ that the drug could work is declared ‘dead’? It does not.
            You seem to be dismissing the significance of the timeline. For any given patient in need of an option today, data that will ripen ten years from now are of no real use. What “alternative” medicine does is apply promising, but not truly ripe, data so that today’s problem can be addressed today. The down side to this, of course, is that the agent in question may be ineffective, and potentially dangerous. The up side is that when they are right, they are right ten years or more before we are.
            The less profitable the product, the longer the timeline to get a critical mass of research done.
            Because patient need is immediate, and data generation is slow, there is a need to make the best use today of the data we have today. That simple imperative leads to therapies for which the evidence is suggestive, but not truly ready for prime time- and thus, integrative medicine. The need to work diligently to differentiate baby from bathwater is, I think, self evident. Best- DK

            My riposte:

            Dr. Katz, thank you for taking the time to respond.
            I am generally overly wordy so I’ll try and be concise as best I can.
            In essence, I am reading your argument as saying that in the face of immediate patient need we should lower the standards of evidence to allow for less evidence based therapies to be administered to our patients and that further this is what “CAM” allows us to do. In other words, “CAM” is nothing more than a term for creating a double standard in which therapies with inadequate evidence to support them can be ethically administered to patients outside of a clinical trial.
            I take multiple issues with this approach and this argument.
            First and foremost it does not at all explain how you can possibly find homeopathic treatments to fit into this proposed paradigm. By what possible rationale can you assert that homeopathy is a “promising, but not truly ripe” modality? If there is one “alternative medicine” that can be less promising I cannot think of one. This can be repeated for nearly all things labeled “CAM”, including many of which you are on public record as advocating (or at least having administered to patients).
            But to address the actual argument you are offering here, it still fails to provide any reasonable rationale for the notion of calling these lower-evidenced therapies “CAM.” Why create a separate category? If the premise is simply that the (admittedly flawed) machinations of medical research are too slow in certain regards, then it makes no difference whether something is “CAM” or not. There is no special validity that somehow grants a higher prior plausibility to something labeled “CAM” than any other random thing you may wish to experiment on patients with (and make no mistake, providing an a treatment in the absence of evidence is experimentation). In fact, you explicitly make that argument but to a degree I am forced to disagree with. Was it not you who said:
            I would not deny the implausibility of the therapeutic influence from not touching, nor contest the improbability of healing messages left behind by molecules diluted out of solution. But once we acknowledge that little could be more unlikely or wondrously implausible than a handshake, the topic of plausibility must be broached with greater purpose. I don’t understand homeopathy, or believe in it per se. I find it inexplicable and farfetched, but perhaps slightly less so than the experience of a caress, and incalculably less so than our existence.
            Neglecting the fact that you are attempting to say that everything is so equally implausible as to be equally plausible, does this not directly contradict the idea of giving an special quarter to something labeled “CAM” as being somehow more likely to be useful in the absence of evidence?
            So how on earth does one pick from the literally limitless possible therapies without evidence to experiment on our patients with? And how would you know if it worked? You say:
            And the anecdotal evidence that homeopathy might be effective was brought up by the naturopaths. We tried it. It worked.
            Besides the fact that there are anecdotes for everything from alien abductions to mind control, you simply cannot say “it worked” because such interactions can, by definition, only demonstrate correlation, not causality. To say otherwise is to abandon the science you claim you believe in.
            One place we do agree is when you say, “patient need is immediate, and data generation is slow, there is a need to make the best use today of the data we have today.” But if you are resorting to using homeopathy and listening to naturopaths then you are very clearly not making the best use of the data we have today. At that point one may as well be trying to use unicorn tears to address immediate patient needs.
            The failures and flaws of the current research paradigm – the one that declared CoQ10 dead – do not magically validate incredibly implausible and unproven claims. As Ben Goldacre said, flaws in aircraft design does not mean that magic carpets can fly. I would argue that using CAM as a crutch to defend what would otherwise be unethical patient care – either providing placebo medicine or doing experimentation on humans without IRB approval – is contra to your stated claims of giving patients needed treatments in an accelerated timeframe.

            And his brief response:

            Actually, I prefer no separate category. What matters is how we proceed when we have exhausted all of the ‘high quality’ evidence, but our patient’s need remains inadequately addressed. Call that CAM, or ‘the next best thing,’ or the ‘art’ of medicine. The rubric matters little; getting the job done matters a lot. The method we use in my clinic is the CURE construct on p. 27 of this paper- [link]

            And my most recent response, which I aver he will either dismiss with a brief handwave or simply not respond to at all:

            Once again, thank you for your time Dr. Katz.
            Superficially we certainly agree. I wholeheartedly agree that ultimately getting the job done is what matters and there are, as you know, many barriers to achieving that in practice beyond the limitations of scientific knowledge.
            Your CURE construct is also superficially agreeable. But it also strikes me as excessively vague. It also, once again, does not jibe with your use of homeopathy. All of your categories include a patient preference for something that works. Homeopathy cannot work.
            It seems that here we disagree on the what constitutes that scale of evidence. Homeopathy is a good litmus test because it cannot possibly meet any definition by your own rubric that exceeds a “never” in terms of utilization frequency. Yet you seem to have used homeopathy at the suggestion of a naturopath, which goes against your own (albeit vague) recommendations.
            Which raises another point from the paper you linked – your standard is:
            As the term CAM refers to any therapy or provider outside the mainstream, any modicum of efficacy or legitimacy satisfies this label. The CAM disciplines with the most promise of successful integration into conventional medicine are those with tangible standards. Specifically, those that have accredited training programs, national certification, standardized education, and government regulation and licensure.
            …essentially nonexistent. And certainly not at all based on actual scientific legitimacy. By this standard if a sect of voodoo priests had enough lobby power in Congress they would be deemed worthy to collaborate in patient care and offer suggestions for treatments. And scientific legitimacy is demonstrably not a requirement for accreditation, standardized education, or government regulation. Bob Jones University is a prime example of this, as is Bastyr and the entire field of naturopathy, which you none the less seem to embrace. You even say:
            The ultimate goal of integrative medicine should be to make the widest array of appropriate options available to patients. Appropriateness should be predicated on fundamental considerations that pertain equally to conventional and CAM practice: treatment safety and treatment effectiveness. Treatment safety and treatment effectiveness must, in turn, be interpreted in light of the available evidence
            Once again we agree in principle, yet in execution something is profoundly lost. The entirety of your argument – and this particular paper – boils down to nothing more compelling or novel than saying we should follow evidence, starting at the top and working our way down as needed. This is something I knew before starting medical school but every first year student learns (or should at least). The only difference is that you seem to have no limit as to how low down the evidence totem pole you are willing to go. If a naturopath recommending homeopathy seems like a reasonable option, why not every old wive’s tale that any random person can conjure up?Do we not owe it to our patients to do more than just flail at them with every nostrum we can throw at them, no matter how ridiculous?
            There are limits to medical and scientific knowledge. Limits that are continually pushed farther and farther out. Not fast enough, but we can (and should) always feel that way. When we’ve reached those limits, abdicating our responsibility to our patients to understand, to empower them to cope and manage their condition in favor of what are nothing more than wild guesses at best is no better than the heavy paternalism of our forebears.
            If you genuinely do wish to “get the job done” (and I truly believe you do, as do I and all of our colleagues) abandoning the principles of rigorous scientific inquiry to the ilk of naturopaths, acupuncturists, TCM practitioners, and chiropractors is not the way to do it. One does not move forward by traveling back in time to pre-scientific nostrums, nor do we improve patient care by abandoning standards.
            I still genuinely fail to understand what value your proposed integrative medicine adds to patient care beyond treating ourselves and the patient to placebo medicine.

            I am open to any thoughts, critiques, things I have missed or misunderstood from this esteemed commentariat.

            (and here’s to hoping all my HTML tags are correct)

            1. kaitch says:

              Beautiful! But will it be enough to overcome the cognitive errors and dissonance? I hope so..

            2. Badly Shaved Monkey says:

              I note that Katz utterly failed to respond to your specific comments on homeopathy. I wonder why. Could it be that he knows full well that he has no good answer to that question?

              There are times when I sorely regret that there is no means on the interwebs to force people to stick to the points put to them and answer the damn question.

            3. Harriet Hall says:

              Well done, Andrey! You make infinitely more sense than he does.

              1. Andrey Pavlov says:

                Thank you all for the comments and kind words. Yes, Dr. Katz continues to refuse to address his use of homeopathy. And I once again will not let him off the hook.

                Dr. Katz has responded again. As have I. My comment is awaiting moderation (likely because I included a number of links). However, once again, his response and mine are reproduced here in full. (And yes, it seems that Dr. Gorski and I share a passion for logorrhea. I tend to think though that complex and nuanced discussions simply cannot happen overly succinctly, particularly on contentious topics).

                Dr. Katz’ response:

                I disagree that every medical student learns to work along a hierarchy of evidence, turning to the ‘next best thing’ most likely to help a patient in need. I think many learn that there is either a meta-analysis or large RCT to back up a therapy, or it should be ignored entirely.
                I would also note that forces in our culture conspire against the utilization of non-proprietary, low-profit modalities. It’s just naive not to notice this, or think otherwise.
                Finally, there are ‘traditional’ treatments that in many cases have been used for centuries. While the accumulation of such experience is no substitute for randomized trials in proving efficacy, it can serve quite well to establish the high probability of safety. That, of course, is an important consideration- since what matters ultimately is the risk/benefit ratio. When risk is nil, and options are few- even a slim chance of therapeutic benefit may be worth taking.
                What I am pleased to see is that we are not really debating evidence, or nomenclature- we are debating methods of practice, HOW to apply evidence to greatest effect. That, I believe, is the correct focus. The notion of ‘this or that,’ ‘conventional or alternative’ is a distraction. What we should care about is: what is the best thing I can offer any given patient in need, and how do I get there from here? Were we all to devote our efforts to that challenge, I think we- and more importantly, our patients- would benefit considerably.

                And my response:

                Dr. Katz, I once again genuinely thank you for your continued discussion in the matter. I can absolutely assure you that I care not from where or whom a therapy comes – so long as I can be convinced it can help my patient I will use it.

                I find it interesting that you disagree on the topic of medical students learning the hierarchy of evidence. In my first year of medical school we had an entire year-long course on it, with exercises, projects, and questions on our exams pertaining to it. Similar for a number of friends and classmates at other medical schools. Perhaps things have changed since you graduated? Or perhaps my small sample size is biased. In any event, I wholeheartedly agree that it should be taught to all medical students in a rigorous manner and with an added emphasis on Bayesian frameworks which incorporate all relevant evidence, including bench sciences, to inform decision making. The idea that only RCTs and meta-analyses can inform decisions seems perverse to me (and indeed has been dubbed “methodolatry” by some) and is not at all what any of my colleagues and classmates think is appropriate.

                But that hierarchy of evidence cuts both ways. For example, when there are equivocal clinical studies in homeopathy, we can look at the bench sciences to inform us that the prior plausibility is so low that equivocal studies can be rightfully regarded as resoundingly negative. A point on which you have failed to expound – your own admitted use of homeopathy with patients.

                You certainly make a valid point about perverse incentives (as I like to call them) nudging us against non-proprietary, low profit modalities. There is a very good reason why my institution has banned drug company lunches for many years and why I support such initiatives. But that still does not justify the use of unproven or disproven modalities in patient care. We can – and should – lament when we are at a lack of tools and knowledge to help our patients, but I fail to see how picking something at random is any better than admitting the limitations of our current abilities. It seems to me much more productive and better for our patients to instead focus our efforts on improving the process.

                Which brings me to the idea of “traditional treatments that… have been used for centuries.” I wholeheartedly disagree that this is a valid surrogate to use for establishing the probability of safety. To use a cliche, bloodletting was used for many thousands of years and it is clearly not safe nor therapeutic. But in a more serious example (of which there are myriad) I would like to draw your attention to aristolochia. That is an herb that was used for at least many hundreds of years, if not thousands, and is in the Bencao Gangmu, now known as the Compendium of Materia Medica of Traditional Chinese Medicine (TCM). The Bencao Gangmu was compiled in the 16th century and there is evidence of the use of aristolochia dating back to the 1st century CE and even ancient Egypt. By your argument one would expect that to be an excellent establishment of a high probability of safety. Yet, in 1993 it began to be noted that people who ingested this herb had unusually high levels of urothelial cancers. A decade later it was noted that so-called “Chinese Herbs Nephropathy” and “Balkan Endemic Nephropathy” are likely the same thing and finally in 2013 it was demonstrated that aristolochia is a potent carcinogen, with it’s effects not limited to patients ingesting it, but also the herbalists producing it. As is noted in this study a full one-third of the population of Taiwan was prescribed something with aristolochia in it. In the words of the authors:

                …it is likely that upper urinary tract carcinomas and their attendant aristolochic acid nephropathy are prevalent in China and other Asian countries where Aristolochia herbs have been used for centuries in the treatment and prevention of disease, creating a potential public health problem of considerable magnitude.

                By your proposed approach to judging the potential safety of therapeutics, aristolochia would be a reasonable therapeutic to try (prior to 1993 and arguably up until the early 2000′s) as it meets all of your requirements as outlined in your CURE paradigm: it has been used by many cultures for thousands of years (probable safety), it would come on the recommendation of a person trained in an accredited program, with national certification, standardized education, and government regulation and licensure (an acupuncturist/oriental medicine specialist; possible efficacy), and unclear scientific evidence of efficacy (ambivalent evidence of efficacy prior to 1993). In our hypothetical patient for whom we are low on options, it could not have been argued by you that trying aristolochia would be anything but acceptable.

                And yet, we would have been exposing our patients to a greatly increased risk of cancer with no evidence of benefit and no rational reason to assume there would be, beyond TCM use based on pre-scientific approaches to pathophysiology.

                My own background includes an undergraduate degree in medical anthropology in which I studied many different systems of medicine, as well as advanced coursework in molecular pharmacology, and post-graduate research in pharmacognosy (specifically investigating the anti-senescent properties of botanical extracts). This is but one of many examples of the pitfalls of assuming safety based on proxies such as traditional use and an illustration that relying on traditional use as indications for therapy is almost the same as walking into a field and picking a random plant to give your patient. Even thousands of years of use is worthless if the results aren’t carefully recorded. That’s why we invented science in the first place.

                The key to your argument is “when risk is nil” – but that is not something I believe can be established based on the methods you are proposing. And it is well demonstrated that something is more likely to harm or do nothing than be of any benefit. Else we would have our patients chewing on yew trees and periwinkle flowers and the field of pharmacognosy would be of very low value.

                I would posit that in cases of few options the best thing we can do to genuinely help our patients is to support and empower them, not give them placebos or experiment on them. If I had tried aristolochia and later learned that I was likely the cause of my patient’s urothelial cancer and nephropathy that would seem to outweigh any slim chance of benefit for both of us.

                In conclusion, I do fully agree with your conclusion in principle. But I disagree that a “more fluid form of evidence” as you describe is the way to achieve those laudable goals. There is no such thing as a free lunch and with any intervention that could possibly have benefit there is also necessarily the possibility of harm. Without due diligence beforehand, we have absolutely no idea where that balance may lie and are betting on the benevolence of Mother Nature and the wisdom of pre-scientific thinkers. Those are not bets I would take, if I were on the other side of the exam table.

              2. Harriet Hall says:

                Katz said “many learn that there is either a meta-analysis or large RCT to back up a therapy, or it should be ignored entirely.”

                He couldn’t be more wrong. He is setting up a straw man and a false dilemma. Anyway, even if that were true, medical students would quickly learn otherwise by reading medical journals. The American Family Physician, published by the AAFP and used by thousands of family physicians for CME, regularly makes treatment recommendations that are clearly classified in a hierarchy of evidence from A to C, where A is consistent, good-quality patient-oriented evidence, B is inconsistent or limited-quality patient-oriented evidence, and C is consensus, disease-oriented evidence, usual practice, expert opinion, or case series. And each recommendation is referenced by articles from the medical literature.

              3. Andrey Pavlov says:

                He couldn’t be more wrong. He is setting up a straw man and a false dilemma.

                I agree. I couldn’t imagine what my medical school curriculum would have been like without the discussion of the EBM hierarchy of evidence, the ideas of Grade A, B, C, D evidence, etc. We learned about PICO, etc. And even if he is correct that still doesn’t justify how he uses (and often doesn’t) the evidence.

  9. Badly Shaved Monkey says:

    “We must do something” seems to be at the heart of Katz’s problem. And when he runs out of good ideas I think he turns to bad ones.

    I came across the same thinking recently at a veterinary meeting where a noted UK vet orthopod presented data from a large series of elbows he had operated on with no controls for comparison and based his continued insistence on a number of surgical procedures for these cases on the pain that the animals experience and the our obligation to “do something”. So it’s not just the woos that are vulnerable to this fallacious thinking.

    I think we have a problem in the mindset of some clinicians. We take it as a personal affront when we can’t fix things. Some adapt, and can cope with the graceful management of incurable diseases. Some seek arenas that offer tidier solutions. Some resort to nonsense. I hope I can restrict my practice to the first two areas.

    1. Andrey Pavlov says:

      We must do something” seems to be at the heart of Katz’s problem. And when he runs out of good ideas I think he turns to bad ones.

      Even worse than that, he turns to the worst ones. There are much better ideas than resorting to proffering homeopathic nostrums whilst sticking your fingers in your ears and saying “La la la la la la!”

    2. simba says:

      As a patient I’d prefer to be told ‘Well, there are no evidence-based things we can do for this’ in these kind of situations. The alternative is having the doctor lie to me.

      It’s like being told ‘that is not serious and will go away by itself’. Way better than having antibiotics or whatever. It means I feel I can trust the doctor when they say ‘That is serious’, ‘this treatment might help’.

  10. steney01 says:

    According to the 2014 Medscape physician lifestyle survey, 38% of physicians (both above and below 45 yrs of age) have themselves used a CAM treatment. They point out that this is the same % as the general population. I guess even intense medical training does not shield one from the powers of woo.

    1. Andrey Pavlov says:

      According to the 2014 Medscape physician lifestyle survey, 38% of physicians (both above and below 45 yrs of age) have themselves used a CAM treatment.

      Also a factor of how CAM is defined. I do yoga, I (try) to eat a balanced and health diet with lots of greens and veg, and I sometimes meditate and reflect on my own mental state (I once even did it in a sensory deprivation tank). Does that mean I use CAM? By most definition in these sorts of “studies” and polls it would. But that is not CAM.

      It would be interesting to see the actual definition and distribution of CAM, if you have a link handy.

      1. steney01 says:

        http://www.medscape.com/features/slideshow/lifestyle/2014/public/overview#9

        They’re using a wide definition, including some practices you mention. They do also state, however, that acupuncture was the most commonly used CAM treatment among physicians. So it’s still sort of unclear what the % would be who use only the most egregious CAM examples I guess.

        1. Andrey Pavlov says:

          Unfortunately they are rather broadly defined and not clearly delineated. There is considerable overlap in non-CAM practices called CAM, but the interesting question would be whether the “hard” CAM’s (like ayurveda, TCM, Reiki, etc) have a differential use.

          But yes, I think the point still stands: most physicians are not scientists and are just as prone to lazy thinking as anyone else. I would also argue (and have in the past) that at least a decent chunk of this “CAM” use is from people with disposable income to waste on things that do nothing except make you feel as if you are being healthful like vitamins and supplements. Physicians do tend to have more disposable income and can look at something as being low risk and give a shruggie “why not.” Acupuncture can be explained by how it is consistently portrayed in both the media and the literature, with quite literally thousands of studies many of which the methods and results don’t match the conclusions.

          1. The studies are trapped in the mythology and not the science. So I would redo all of them and advise or devise a better study.

            Don’t be fooled by all of those old flawed studies.

          2. Windriven says:

            So what is stopping you, Steve? You have something to prove. You can either whine about the unfairness of it all or you can go out and prove it.

            But I’m not convinced that you share an appreciation of evidence as it would be accepted by the scientific community. Still. there are many accomplished researchers in these pages who would likely be happy to offer constructive criticism and otherwise assist in your effort to structure a compelling trial.

    2. Stella B. says:

      I’ve even tried glucosamine. It didn’t work, but then again I failed to truly believe.
      I had a patient once who swore that “Dr. Wallach’s Mineral Toddy” had turned his hair back to it’s original color despite the fact that all I could see was a beautiful thick head of silver hair. It’s easy to fool yourself — no matter how smart you are — into believing what you want to have happen.

      In the early days of the HuffPo I got myself banned from commenting for calling Jay Gordon a “quack”. I was right and I stopped going there.

  11. Calli Arcale says:

    He considers homeopathy more plausible than the experience of a caress?

    Seriously?

    So, if he’s accepting personal experience of homeopathy appearing to work as justification, doesn’t thinks mean he has had less personal experience of caresses? ;-) Snark aside, what a sad and tragic way to view the universe, where the wonderful beauty and extraordinary passion of existence is relegated to “implausible” merely because . . . honestly, he didn’t really explain why he finds the fact of his own personal existence harder to accept than homeopathy, which *presumably* he has less personal experience of.

    He has more personal experience of homeopathy than his personal existence? That makes zero sense, but it’s sort of what he’s saying here, which means he really didn’t think this through. This, in other words, is a rant typed out while angry rather than a truly reasoned defense. Gorski is right; he took this way too personally. On some level, perhaps he understands that he’s being hypocritical, and he doesn’t like that, but as many people do when facing cognitive dissonance, his solution is to try to drive away anything that makes him face it.

    1. Andrey Pavlov says:

      So, if he’s accepting personal experience of homeopathy appearing to work as justification, doesn’t thinks mean he has had less personal experience of caresses?

      That and as Cosmos showed us, we actually can explain how and why the caress that never actually happened still feels like it did. We know what is going on there and can readily explain why although technically from a pedantic physicists’ standpoint we don’t ever actually touch each other from a practical standpoint it doesn’t matter. The same cannot be said for homeopathy.

      I’m reminded of the joke about a group of post-docs, half of whom studied English lit and the other mathematics. They segregated the men and women on opposite sides of a room and lined them up. They told the men to walk precisely half the distance to the women. Then half again. And again. The mathematicians stopped, dejectedly realizing they would never be able to make it all the way across the room. The English lit contingent continued, knowing they would get close enough for practical purposes.

      1. Calli Arcale says:

        *grins*

        Well, I always felt we English majors were actually very practical people. ;-)

      2. Chris says:

        Here is another version of the joke, though it involves mathematicians, physicists and engineers:
        http://mathworld.wolfram.com/ZenosParadoxes.html

        Guess which group went with the “practical purposes” answer.

        1. Windriven says:

          :-)

        2. Andrey Pavlov says:

          Yes, an excellent version. Better than mine off memory

          1. Chris says:

            And one your girlfriend will heartily approve of!

            (The father of one of my younger son’s friends in high school is a math professor. He gave a presentation on the nuances of infinity, and afterwards I had had to tease him that for all practical purposes those half steps get you there.)

  12. Dee says:

    I recently attended an integrative medicine seminar at the hospital in which I work. I am convinced this is all part of marketing to stay competitive. The attitude is to give people what they want even if it doesn’t work. The buzz word used was “science informed medicine”. I smell a new blog.

  13. Sastra says:

    I don’t understand homeopathy, or believe in it per se. I find it inexplicable and farfetched, but perhaps slightly less so than the experience of a caress, and incalculably less so than our existence.
    We are. Therefore, I think, we must be plausible. But frankly, I don’t see how.

    This reminded me of something, but I couldn’t think what.

    Then I remembered.

    1. Andrey Pavlov says:

      Sadly that is almost exactly spot on Sastra.

    2. Windriven says:

      Classic!

  14. Tazia Stagg says:

    Thank you! Whenever I notice something appalling about medicine, I can usually count on you to have covered it.

    I’m a preventive medicine physician* and I discontinued membership in my professional society, the American College of Preventive Medicine, for a number of reasons. The first item on my list of Why I Don’t Belong in the ACPM is its relationship with integrative medicine. You can find out more about how the ACPM associated itself with integrative medicine (by accepting a HRSA grant and establishing IMPriME) here http://www.acpm.org/resource/resmgr/pressreleases/pr_2012_nccim.pdf and here http://www.imprime.org/
    David Katz is the chair of the IMPriME steering committee, so I blame him for this degradation.

    *In case you haven’t heard of it: It’s not you, it’s us. We haven’t promoted ourselves. It’s an actual specialty; I’m board-certified** in Public Health and General Preventive Medicine.
    **by the ABPM, a member board of the ABMS.

    Here’s my perspective. The main gap in conventional healthcare that Integrative/Complementary/Alternative folks are trying to fill/exploit is the result of preventive medicine physicians’ absence and failure to meet Americans’ needs. It’s time for us to establish a role in direct patient care.

    1. agitato says:

      “It’s time for us to establish a role in direct patient care.”
      It’s a good idea. What would that role look like?

      1. Tazia Stagg says:

        Thank you. I’m afraid that’s a good question!
        All I know is what I’m about to try…

  15. DavidCT says:

    As someone in healthcare I have to wonder about the ethics of Intigrative medicine. It is an ethical violation of informed concent for me to knowingly offer placebo treatments as real treatments. At the same time it seems fine for a true believer like Dr. Katz to offer magic beans to his patients as medicine. Does just having a postmodern view of snake oil make it somehow ethical to use?

  16. Lytrigian says:

    Moreover, there are virtually no situations in which CAM or “integrative medicine” is the only option left, but Dr. Katz quite consciously portrays the choice thusly… Indeed, he portrays himself as having been “led to” integrative medicine” by this dilemma…

    Isn’t this tantamount to an admission of incompetence or malfeasance on Dr. Katz’ part? If he frequently ran into situations where he could think of no further evidence-based options for a patient, and then failed to refer that patient to someone else who might be able to offer more evidence-based treatment options, that suggests he was either not sufficiently familiar with available treatments, or unethical for failing to refer a patient to someone more qualified.

    That he further resorted to magic to treat his patients only makes it worse.

  17. Missmolly says:

    It’s so depressing that Katz has clearly lost sight of the art of medicine. I think people forget that you can give patients a great ‘healing experience’ (to co-opt a hateful CAM term!) without needing to offer them expensive fakery. By really listening, focusing on and validating their concerns, giving them realistic expectations and providing a structured plan for a gradual progression towards a subjective sense of ‘wellness’ (gah!), you can have successful and rewarding patient encounters without strictly ‘curing’ them outright.
    It sounds too much like Katz has fallen into the false thinking that patients often have- that there is a silver bullet cure for every problem that works within 10 minutes, has no side effects and tastes like rainbows. As doctors, we have the responsibility to help patients understand that medicine doesn’t generally work like that, regardless of what they see on TV. In my opinion, it’s both medical malpractice and lazy to tell them that maybe magic will help them; and that maybe they should shell out a couple of hundred bucks just in case this beautifully packaged shaken water is the one true cure for them!
    This article in an Australian GP journal on an approach to ‘heart-sink’ patients really rang true to me: http://www.racgp.org.au/afp/2014/april/blame-shame-and-hopelessness/
    As an aside, Katz’s comments feel close to those relativist ‘whoa, man, we can never really know anything; and, like what IS truth??’ discussions I had as a kid with arts students at uni. We thought we were pretty clever and deep then, too :)

    1. Andrey Pavlov says:

      Absolutely agreed MissMolly. Only one thing I would add to the list (already implied by you): empowerment. Giving your patients knowledge and resources to actually understand the issue at hand and the limits of our ability to treat them gives them power, confidence, and the ability to actually cope and lead better and more productive lives. Doing what Katz is doing – giving out placebos – is nothing short of infantilizing.

  18. If Dr. Katz (not me) wants to be a card-carrying member of the evidence-based medicine club, here is the opportunity: join the Society for Science Based Medicine.

  19. PMoran says:

    “See what I mean. No one—and I mean no one—here argues for abandoning the patient who fails to get well when treated with science- and evidence-based treatments.”

    I believe I understand the problems that drive Katz, although not being entirely satisfied with his personal solution.

    I pointed out in recent comments how evidence-based medicine has reduced doctors’ management options for many common complaints without offering many very effective or suitably safe evidence-based substitutes; this in the face of historically high public expectations of medicine, and an ingrained, instinctive compulsiveness behind the consumption of medical services and products — at minimum through the willingness of many “consumers” to keep trying out nearly anything that might help when faced with ongoing medical problems.

    Also, the history of medicine, the phenomenon of CAM itself, and considerable evidence relating to the complexity of influences within medical interactions have demonstrated how mutually satisfying, ongoing medical relationships can occur even in the absence of intrinsically active treatments. Quackery would not exist if this were not so. The reasons are multiple and complex.

    Thus it comes about that evidence-based medicine can require its adherents to practice medicine with one arm tied behind their back, so to speak, while at the same time encouraging competition in the form of an “alternative” medicine that can pose its own health risks. For all its virtues EBM/SBM has helped to create this “external market” for dubious methods. It will undoubtedly continue to do so.

    So Katz is asking “what help does EBM/SBM offer doctors when the point is reached where everything has been said, every evidence-based treatment has been tried, and there is no one left for the patient to be referred to? (This last is not a problem for us medical specialists, who happen to be doing most of the writing on this blog. We can always gracefully bow out by returning responsibility for the patient to their primary care doctor. Dr Gorski has even allowed that his choice of specialist career as a surgeon has enabled him to avoid some of the matters that might be bothering Katz.)

    If we are truly honest with ourselves, there is no good science-based answer, while ever patient symptoms continue unabated, and no matter how much patient empathy we display. The patient wants ongoing medical care and Dr Katz wants to continue to care for him, having been trained to believe that it is his job to do so, and that he will be failing in his duty somehow if he cannot.

    Yet as Katz implies, the strict application of EBM often has the effect of abruptly terminating the usual basis for such interactions, leaving nowhere to go. Katz’s caring instincts are being frustrated, he risks losing his patient to potentially darker forces, and he is looking for answers.

    He is also questioning what rights science has over medical practice when it is not offering solutions. I am sure he is honest in his belief that he is not looking to overturn medical science. Nor is his approach likely to do so.

    Doctors are reacting to the same problem in different ways. Katz seems to be trying to arrive at an intellectual compromise with CAM. Others (perhaps 50% of doctors) respond by using placebos, often in the form of weakly credible varieties of CAM. Some respond in possibly the worst possible way, by the inappropriate use of powerful pharmaceuticals.

    Understanding all this, what should knowledgeable colleagues be saying to Katz? How should this dialogue progress?

    1. Windriven says:

      “[H]istorically high public expectations of medicine, and … the willingness of many “consumers” to keep trying out nearly anything that might help when faced with ongoing medical problems. ”

      It isn’t hard to understand that impulse: the patient with an intractable problem expects House. If Dr. A isn’t House, try Dr. B. Execute a recursive loop until House is found and the problem is solved.

      So forgive me for simplifying this to absurdity but mine is a simple mind: I take my much loved 1976 Chevy Cavalier* to the shop because it isn’t running properly. The mechanic runs a battery of tests: compression, manifold vacuum, timing, spark efficiency, fuel flow … but comes up dry. Nothing testable reveals the fault yet the car runs like crap. Does the ethical mechanic say: “I recognize that there is a problem but I am unable to diagnose it,” or does he say, “well, there is some chance that this is caused by worn muffler bearings** so let’s change those?” Of course this sets up something of a false dichotomy as there are a range of things in between but I’m not clever enough to imagine one that is appreciably more acceptable than one of those extremes. If you can, I’d like to hear it.

      I think it all boils down to the “historically high expectations of medicine” and the flip side of that coin: the high personal expectations and desires of the physician to heal the ill. The physician probably doesn’t want to say and the patient certainly doesn’t want to hear – “I dunno.”

      But what are the ethics of moving from SBM to sCAM in that circumstance? Isn’t there something in between? At some point there won’t be an RCT or even a Cochrane cowpie-a-palooza*** to consult. But there is prior plausibility and the gray areas that shadow the proven treatments. And of course there needs to be full disclosure and informed consent that this is moving off the path of science based medicine.

      *A lousy pick. The Chevy Cavalier usually didn’t run long enough to start to run badly. Insert your own favorite ill-conceived automobile.

      ** I actually heard this sold to a woman by a guy I knew who owned a service station. It wasn’t enough for him to screw the customer, he had to do it in an outrageous way that would have been humiliating if the customer knew anything at all about automobiles. He was that kind of guy. Of course, there is no such thing as a muffler bearing.

      *** I’d offer apologies to Billy Joel but I don’t particularly care for him, for his music, or for the Lolapalooza schtick. But it kind of rhymes with the Cochrane modus of mashing together a bunch of often second rate stuff and pronouncing it brilliant.

      1. MadisonMD says:

        But what are the ethics of moving from SBM to sCAM in that circumstance? Isn’t there something in between?

        Yes, that’s just it. There are dozens of plausible things without RCT that could be recommended.

        I would add that honesty should also be included in this discussion. I am sympathetic to much of PMoran’s ideas. However, honesty is breached if homeopathy is recommended (unless it is admited to be a simple sugar pill).

        1. irenegoodnight says:

          “There are dozens of plausible things without RCT that could be recommended.”

          I think there is good evidence that hot baths (aided by candles and a glass of wine) provides excellent treatment for just about anything that ails me for which my internist has little to offer.

          But, you see, the quacks don’t recommend this because (to turn their argument around) you can’t patent it– or put it in a bottle and charge an obscene amount of money for it!

          1. Andrey Pavlov says:

            But, you see, the quacks don’t recommend this because (to turn their argument around) you can’t patent it– or put it in a bottle and charge an obscene amount of money for it!

            Hmmmm….. now that is a good idea. Maybe I can find a way to charge my patients for recommending such interventions. But how?

            Perhaps I could call it something fancy like, I dunno….

            Standardized Prepared Alleviation! Yes. I like it.

            Of course, catchy acronyms are great too. They help with sales. So I could just call it “SPA.”

            And I could even set up a special office, with all of my own equipment, proprietary adjuvants (I could call them “SPA aids”), and a staff to cater to your needs.

            And for the toughest cases, I could suggest a day off work to go and visit my center. It would be a special treatment, called “Day SPA.”

            I bet you I could easily charge upwards of hundreds of dollars per day!

            Genius I tell you. Genius.

          2. MadisonMD says:

            I think there is good evidence that hot baths (aided by candles and a glass of wine) provides excellent treatment for just about anything that ails me for which my internist has little to offer.

            Agreed. If not diagnosis is made, the message should be: (a) Your symptoms are real; (b) Fortunately they are not a sign of a serious disease; (c) I don’t have scientific data on what to do for this situation, but I would suggest we try hot bath/rest/exercise/stretching, etc. etc.

            Honest, not abandoning the patient, and not resorting to quackery. Why not advocate this, Dr. Moran?

            1. PMoran says:

              “Why not advocate this, Dr. Moran?”

              Ha! Madinson, this is closer to the bone of the matter than it might first seem.

              You see, the instant someone began recommending this (hot baths, candles etc) as medicine, some well-meaning sceptical kill-joy will come along and write a ponderous dissertation on how “your evidence that this is helpful is anecdotal, there are no placebo controlled trials of this approach, candles are obvious “woo”, there is no physiological plausibility beyond transient non-specific influences that will be gone by the next day and you are encouraging one of the scourges of modern society in the resort to alcohol for life’s ills.”

              This is a good illustration of how “science”, as understood by some, does not always hit the sweet spot of any particular problem among the infinite variety that medicine dishes up.

              “I’m with you right up to that last paragraph. I don’t think it follows that doctors need to acquiesce to the patient’s impulse to pursue quackery any more than I think astronomers need acquiesce to someone’s desire to see an astrologer because astronomers can’t foretell the future. ”

              I can agree. Recent history is consistent with the hypothesis that the harder the line that is adopted against unproven methods (the sceptic’s battle standard has the words : “ALL of medicine should be held to the one standard”), — indeed even the higher the standard of informed consent that is applied before prescribing conventional methods, the more patients with some conditions will be inclined to turn instead to folk medicines, CAM and alternative practitioners. They will also do so earlier within each illness episode, sometimes even before a predictably CAM-disapproving doctor is even consulted — and probably partly because of the level of disapproval anticipated and a penchant towards the over-use of pharmaceuticals that Dr Novella and others here admit will inevitably have ill effects for some.

              So the medical sceptic cannot pronounce upon how things should be and then slip away scot-free — he cannot avoit the dilemma that Dr Katz and his ilk should not be allowed to avoit the

              And that one legitimate approach for science and logic. Nevertheless, reality sucks, and the medical sceptic should not imagine that he can say this and slide away scot-free, avoiding the dilemmae that Dr Katz and his ilk face every day by simply ignoring them.

              1. PMoran says:

                Sorry, another unfinished post. Trying to do too many things at once, I fear.

              2. MadisonMD says:

                You see, the instant someone began recommending this … some well-meaning sceptical kill-joy will come along and write a ponderous dissertation on how “your evidence that this is helpful is anecdotal…

                If I told my patient that the modality lacks evidence and it doesn’t involve personal profit and I don’t refer my patient to an untruthful altmed provider, then I am OK with it.

                I would still like a bit of plausibility and honesty– e.g. “A hot bath won’t likely eliminate the problem but it might make you feel better for a while.” I still have a problem with Katz embracing homeopathy– it is either dishonest or ignorant. This seems to be the one sticking point on where I disagree with you.

                …penchant towards the over-use of pharmaceuticals that Dr Novella and others here admit will inevitably have ill effects for some.

                BTW, I agree with you here. You can’t believe the pressure there is from my healthcare colleagues and patients to prescribe gabapentin for every case of neuropathy and zolpidem for every case of insomnia. Since reading SBM, I’ve actually become more resistant to prescribing and more likely to recommend non-pharmaceutical methods of symptom management.

              3. Windriven says:

                “Recent history is consistent with the hypothesis that the harder the line that is adopted against unproven methods, … the more patients with some conditions will be inclined to turn instead to folk medicines, CAM and alternative practitioners. ”

                That might well be true. The more I told my teenaged boys that drinking alcohol beyond a certain point didn’t make one more relaxed or have more fun, it just made one stupider may well have inspired them to drink more. For a while. Both of my boys are quite responsible drinkers these days. Don’t know if it is to be attributed to emergent maturity or reflection on stepfatherly advice. I’ll take either.

                The point, I guess, is that speaking unpleasant truth in one’s communications may not have the desired effect – at least not immediately. On the other hand, telling someone what they want to hear – knowing that it is untruthful – begs the ultimate result of your interlocutor, your patient now, realizing later that you were full of sh!t.

                I can speak only for myself, of course, but I can forgive my physician for being honestly wrong (it has happened twice) or for telling me something I don’t want to hear. I could never get beyond having her lie to me.

              4. Andrey Pavlov says:

                You see, the instant someone began recommending this (hot baths, candles etc) as medicine, some well-meaning sceptical kill-joy will come along and write a ponderous dissertation on how “your evidence that this is helpful is anecdotal, there are no placebo controlled trials of this approach, candles are obvious “woo”, there is no physiological plausibility beyond transient non-specific influences that will be gone by the next day and you are encouraging one of the scourges of modern society in the resort to alcohol for life’s ills.”

                What a massive straw man! You should head out to Black Rock Desert with it.

                That is so far removed from anything that has been uttered or implied here I can’t even begin to fathom where you got it from. I mean seriously. Every single author here – myself and Dr. Gorski included – have explicitly stated that we have no problems with taking advantage of non-specific effects. So long as it is in an honest manner. Relaxation and reflection are helpful. And there is evidence to support that. But tricking people into doing it by jamming them full of needles is not. Distraction is a very useful technique. Doing it with magical sugar pills is not.

                “ALL of medicine should be held to the one standard”), — indeed even the higher the standard of informed consent that is applied before prescribing conventional methods, the more patients with some conditions will be inclined to turn instead to folk medicines, CAM and alternative practitioners.

                Gee Peter, it sounds like you think Katz’ was right when he said to me that “I think many learn that there is either a meta-analysis or large RCT to back up a therapy, or it should be ignored entirely.” Something that I find incredibly ridiculous and Dr. Hall felt the same way about.

                Once again, you are trying to burn a straw man. Nobody thinks that way, least of all skeptics such as ourselves. In fact the very premise of SBM is to incorporate more levels of evidence, have a hierarchy that works in concert to inform decisions, and recognize the limitations of the current state of evidence and act accordingly.

                I dare you to find anywhere here where any of us have said anything along those lines. And I can pull up quote after quote after quote showing precisely the opposite.

                So the medical sceptic cannot pronounce upon how things should be and then slip away scot-free — he cannot avoit the dilemma that Dr Katz and his ilk should not be allowed to avoit the

                Well, that just like, your opinion man.

                I say you just don’t seem to understand the tools at our disposal and how to use them. You are basing arguments on limitations that are mere figments of your imagination. Or, at best, are realized only because of practical limitations rather than the absolute limitations you seem to believe exist.

                Perhaps back in your heyday you acted that way. And now you see and feel the error of your ways. But you are rebounding and overcompensating – a lot like Katz. Just because you didn’t find the way to do it right doesn’t mean others can’t and therefore must resort to CAM.

                And yes, ALL medicine SHOULD be held to the same standard. That doesn’t mean that lower quality evidence or transient salutary effects are to be ignored or discarded. It just means that things with no evidence, evidence against them, or reason to believe the risk:benefit ratio is too close to call should not be artificially elevated to meet a higher standard. They should be relegated to their proper place and there should be a bottom limit to what is ethical and reasonable to go down to. But more importantly all other methods – including candles and warm baths – should be exhausted before even considering the lucubrations of sCAM.

    2. Tazia Stagg says:

      You asked “what help does EBM/SBM offer doctors when the point is reached where everything has been said, every evidence-based treatment has been tried, and there is no one left for the patient to be referred to?”

      Assurance. Please provide a specific scenario.

      It’s interesting that the focus is on helping doctors.

    3. Andrey Pavlov says:

      I believe I understand the problems that drive Katz, although not being entirely satisfied with his personal solution.

      I agree.

      I pointed out in recent comments how evidence-based medicine has reduced doctors’ management options for many common complaints without offering many very effective or suitably safe evidence-based substitutes;

      I disagree with your word usage here and what it implies. This statement very clearly implies that there once were more treatment options that have now been stripped away. That is absolutely not the case. Those treatment options were never there to begin with. EBM hasn’t stripped anything away, it has made clear what was there in the first place.

      this in the face of historically high public expectations of medicine, and an ingrained, instinctive compulsiveness behind the consumption of medical services and products — at minimum through the willingness of many “consumers” to keep trying out nearly anything that might help when faced with ongoing medical problems.

      I also agree with you here, but feel you are missing a very important aspect. The worried well and the “preventative” use of CAM, as well as that being driven by ideological motivators (e.g. anti-science, anti-establishment, or otherwise prone to magical thinking). We butt heads on this topic because you continue to assert that the main driver of CAM use is spurred by the failings and limitations of modern medicine. This is, at best, merely a driver of CAM use. And there is plenty of evidence to show that a large bulk is driven by people with more money than sense who feel that if they take [x,y, or z] supplement or do [a,b, or c] “maintenance” treatment they are staving off future medical needs. And there are, of course, the people that are driven entirely by some internal ideology that is more about simply moving away from science and medicine rather than moving towards something they find effective.

      In other words, the best you can argue and the most I will cede is that there is no single main driver of use, but there is a plurality where your particular hobby horse is but just one motivator. By focusing exclusively on those who are driven to CAM by failings and limitations of medicine you are ignoring the actual bulk of what drives CAM use (whether it is one or many things combined that you are ignoring).

      Also, the history of medicine, the phenomenon of CAM itself, and considerable evidence relating to the complexity of influences within medical interactions have demonstrated how mutually satisfying, ongoing medical relationships can occur even in the absence of intrinsically active treatments. Quackery would not exist if this were not so. The reasons are multiple and complex.

      This is completely uncontroversial, particularly around these parts, and oft discussed.

      Thus it comes about that evidence-based medicine can require its adherents to practice medicine with one arm tied behind their back, so to speak, while at the same time encouraging competition in the form of an “alternative” medicine that can pose its own health risks. For all its virtues EBM/SBM has helped to create this “external market” for dubious methods. It will undoubtedly continue to do so.

      I disagree. The non-specific acts eliciting those non-specific effects of CAM practitioners can – and are – also be a part of actual medical practice. EBM does not tie a hand behind our back. Perhaps the system of delivery does, in limited our time. Or our education does, in a lack of emphasis on the interpersonal aspects of medical care. But there is nothing a CAM practitioner is magically capable of doing that I, or any other physician here, is incapable of doing in that regard. I not only have both hands in this fight, but one of mine is vastly stronger as it is backed by evidence.

      I can agree that, to at least some extent, the system of delivery and the stresses of time in providing modern medical care can be considered to create your “external market.” But not EBM/SBM. That “other hand” will necessarily be different in practice by an SBM practitioner, but I have yet to see – and you have yet to present – any evidence that they would not be equivalent. I would even go so far as to argue, in my opinion, that our other hand is also stronger. Because done properly it provides more than mere placation as we find with CAM practitioners, but genuine empowerment to our patients, giving them useful tools that actually do something in their lives. Of course, not everyone will be amenable to this, but neither will everyone be amenable to the lucubrations of CAM practitioners. Where the overall balance lay in the population is anyone’s guess – yours included. But I posit that an approach that favors truth and reality will invariably win the day in the long run.

      So Katz is asking “what help does EBM/SBM offer doctors when the point is reached where everything has been said, every evidence-based treatment has been tried, and there is no one left for the patient to be referred to? (This last is not a problem for us medical specialists, who happen to be doing most of the writing on this blog. We can always gracefully bow out by returning responsibility for the patient to their primary care doctor. Dr Gorski has even allowed that his choice of specialist career as a surgeon has enabled him to avoid some of the matters that might be bothering Katz.)

      Whatever it is that we can do and say, treating our patients like children and going back to the days of strong paternalism is not the answer. And, as another commenter has already pointed out, there are many options before and more efficacious and suitable than resorting to CAM. Passing the buck, as you mention, is not acceptable. And it is not at all and indictment of Dr. Gorski that he recognized the limitations in his own personality in choosing a specialty. But it is an indictment of Dr. Katz that he cannot find a rational way to cope with his own.

      If we are truly honest with ourselves, there is no good science-based answer, while ever patient symptoms continue unabated, and no matter how much patient empathy we display. The patient wants ongoing medical care and Dr Katz wants to continue to care for him, having been trained to believe that it is his job to do so, and that he will be failing in his duty somehow if he cannot.

      Of course there is. And it does not involve magical thinking or turning a blind eye to evidence and offering homeopathic nostrums at the behest of naturopaths. Is it easy? No. Of course not. But regular counseling, psychological/psychiatric care, and fostering a strong patient-physician relationship are all science based ways to approach the problem. Once again, you seem to choose to focus on the exceptions to this, which there will always be. Yet you ignore the exceptions to other CAM options. We will never – no matter what we do – manage to please all the people all the time (to reference one of my favorite songwriters). But it is infinitely better to use the SBM approach, rather than just focus on the few exceptions and assume that means it is all a forever losing proposition to the give up and cede to woo-meisters.

      Dr. Katz can continue caring for his patients without resorting to CAM. Remember that caring for your patient means caring for them. Not giving them pills, or doing procedures, or referring to specialists, or casting magic spells on them. Those are the tools we use, when appropriate, to manifest our caring for our patients. (And obviously the last one is very nearly never appropriate). You are confusing the act of doing something with the act of caring for your patient. Placing a central line in my patient is not caring for him, taking the time to realize the utility and necessity of a central line is caring. The actual placement is simply the physical manifestation of that.

      Yet as Katz implies, the strict application of EBM often has the effect of abruptly terminating the usual basis for such interactions, leaving nowhere to go.

      It is only abrupt if you as the physician act abruptly. And except in less common cases there is absolutely not some abrupt wall wherein the only course of action a physician can take is to simply shake hands, say goodbye, and walk out. Those who do are doing so from personal flaws or forced to by systemic limitations, not because of the dictates of EBM/SBM. You are not looking at the correct source of the problem we both see and agree exists, which is why I have continually disagreed with your approach. It would be right if you were tackling the right problem.

      He is also questioning what rights science has over medical practice when it is not offering solutions. I am sure he is honest in his belief that he is not looking to overturn medical science. Nor is his approach likely to do so.

      On this we agree. As does, I would aver, Dr. Gorski. But that is immaterial – one can also question what rights science has over space travel. That doesn’t mean it is a good question. And his answers are definitely very much lacking.

      Understanding all this, what should knowledgeable colleagues be saying to Katz? How should this dialogue progress?

      Well, my responses are already written here in these very comments, including Dr. Katz’ own, so I won’t bother reproducing them. But the answer is rather straightforward and simple in principle, if not in application.

      We work to change the system such that appropriate expectations are had, that time enough for delivery of appropriate care is possible (that “other arm”), we develop a field of medicine to be able to take extra time for particularly difficult cases (which we already are, and I have the perfect example buried somewhere in my emails wherein a hospital has hired a pediatric intensivist whose sole duty it is to help families understand and cope with their children’s condition on a long-term basis, without any clinical duties to hamper that interaction… I just can’t find the reference at the moment), and so on. The last example is already gaining traction with fellowships and positions in precisely that sort of thing coming to the fore. It has the added advantage of selecting for an individual with the necessary skills and proclivities to do such work. You may try to argue that this is too expensive or impractical a solution. If, as we are saying here, the issues are great enough then the expense is worth it. And providing a cheap and fake patch instead will only serve to worsen the situation in the long run and help much less in the short term.

      What we definitely should not be doing is giving credence to CAM or its practitioners, licensing them, lowering our standards of evidence, “integrating” with them, using their nostrums ourselves, or otherwise passing the buck to shysters and incompetents, no matter how pure and divine their intentions are. Every single field of study and practice has its own version of “alties” and pseudoscience. But ours is the only field that even begins to give them the time of day. And ours is, by my own biased estimation, the field that should be least able to stomach it.

      (As an addendum, I would like to say I absolutely fracking love the new site design because I just accidentally closed my browser instead of selecting all the text to copy it and make sure it wasn’t lost, and when I reopened it all my text was preserved. Hallelujah!)

  20. PMoran says:

    Perhaps this points to a partial answer ” — Dr Katz wants to continue to care for him (the patient for whom he has run out of treatments) , having been trained to believe that it is his job to do so, and that he will be failing in his duty somehow if he cannot.”

    A decade or so ago I was ruminating on these matters, when Rosemary Jacobs (of the grey skin from colloidal silver) responded with something like this: “perhaps doctors should not expect to be all things to all people.” She may not remember the episode, but it was a startling thought to me at the time and I have never forgotten it.

    Why “startling’? Well, I could see no virtue at all to it then. I still strongly held a doctors’ typical proprietary instincts towards medicine. Do we not feel — with some justification — that Medicine is OUR thing ? Surely the whole of medicine should be lodged “safely” (arguable in some respects) under the wings of “we who know best” — as we certainly do on so many very critical matters.

    Perhaps that is a dated concept which is causing some of the trouble for doctors like Katz. . If we are going to be strict “evidence-based specialists” we should not be representing ourselves as anything more than that. We should be educating the public as to what we can’t do so that doctors are not being put under so much pressure to prescribe.

    But this implies that they be permitted to seek whatever other help the patient might choose to seek without too much mean-spiritedness or well-poisoning on our part (and that Katz is surely reacting to) y that is what we should ithin what is inevitably going to be a de facto prulaistic Events, and public opinion. may have overtaken it. We have a complex situation that we would never once have envisaged and to which science alone does not provide a completely clear answer.

    1. PMoran says:

      I don’t know what keys my many thumbs pressed to send that incomplete post.

      I will leave the last paragraph might have simply read —

      But this implies that they be permitted to seek whatever other help the patient might choose to seek without too much mean-spiritedness or well-poisoning on our part (and that Katz is surely reacting to) .

    2. Windriven says:

      I’m with you right up to that last paragraph. I don’t think it follows that doctors need to acquiesce to the patient’s impulse to pursue quackery any more than I think astronomers need acquiesce to someone’s desire to see an astrologer because astronomers can’t foretell the future.

      I’m not suggesting that adults be legally barred from this. But it does the patient a disservice when they cannot trust their physician’s advice to be evidence based – even when that is not what they want to hear.

    3. Andrey Pavlov says:

      Why “startling’? Well, I could see no virtue at all to it then. I still strongly held a doctors’ typical proprietary instincts towards medicine. Do we not feel — with some justification — that Medicine is OUR thing ? Surely the whole of medicine should be lodged “safely” (arguable in some respects) under the wings of “we who know best” — as we certainly do on so many very critical matters.

      This perhaps lends me some insight into your thoughts Peter. You are absolutely correct that in your day medicine was “our thing.” That is no longer the case. It is the “thing” of ours and all the allied healthcare professionals and the patients and families. I agree that this change is slow to come and not there yet. But it is, without question, happening. In ways that address some of the thoughts I had in my response to your other comment and much more than that as well.

      Modern medicine is a team effort. The only caveat is that all members of the team should be playing the same sport and not have members think they are passing fairy dust to unicorns to score points.

      If we are going to be strict “evidence-based specialists” we should not be representing ourselves as anything more than that

      Well, I agree… sort of. From my point of view, however, being a strict “EBM specialist” is not at all limiting in the manner you imply and explicate. Yes, we should be educating the population more as you say, but we can (and should, and do) also do more. Because there is more to do within the evidence based paradigm. It is you, I think, who is unfairly pigeon-holing yourself into a stereotype of what a physician is and can be.

      BTW, I discuss my ideas with many people from many walks of life. Some friends, some new acquaintances, some already very predisposed to or using CAM, almost all with no scientific background let alone medical science background. I have yet to encounter a single person who thinks my approach is unreasonable and have, in fact, had a number of them thank me for allowing them to realize they’ve been wasting their time on CAM. I’ve also had a number of them pay me the highest compliment of all – asking how they can become my patient. But I don’t pigeon-hole myself and what I can do and offer patients in the way that you seem to.

      But this implies that they be permitted to seek whatever other help the patient might choose to seek without too much mean-spiritedness or well-poisoning on our part (and that Katz is surely reacting to) .

      I’m not sure why it implies that or even precisely what that means. Of course patient autonomy should be respected and – as Windriven continually points out – competent adults should be able to do just about whatever they please to themselves. I also agree that mean spiritedness never has a place in any patient-physician interaction. Period. But I don’t know what you are attempting to imply by well-poisoning. Are you trying to say that I cannot tell my patient that in my learned opinion some particular CAM or CAM nostrum makes no sense and either probably or definitely does not work? That I must give a complete pass and remain utterly neutral when my patient confides that she will be seeing a homeopath or a naturopath or taking some herbal decoction?

      1. brewandferment says:

        Andrey, to some extent I sort of understand Dr. Moran’s use of “poisoning the well” in regards to patients using woo. My late mother was quite enamored of various supplements and nutritional nonsense, as well as chiropractors being her go-to person for any and all ailments unless they turned really serious or were obvious (broken bones for one). She had intractable and ferocious migraines for several years in the 70s and 80s that really had no good treatments then although she was offered Valium by the family MD. She refused, said she had 5 little kids under the age of 7 so even if it helped the migraines she couldn’t afford to be oblivious to the goings on in case we killed ourselves or burnt down the house. Which I think was the real cause and start of her forays into woo.

        Even within the last 8 years or so she told my sister-in-law that if one of the grandkids had been taken to a chiroquack early enough that there would not have been an appendectomy (shudder!)

        For various reasons being too long to cover here, Mom was suspicious of lots of government and other authority, despite being a pretty authoritarian parent in several aspects (but not all, she was clearly a loving and caring mom) herself. When my sister got a 3rd degree burn as a small child, after cooling the burn mom applied Vit E oil. I’m not sure that in the early 70′s this was so clear to parents as to how bad this idea was–butter on burns was still a pretty common home remedy then I think.

        Anyhow, to hear Mom tell the story, the ER doc really reamed her for that. Not that he was factually wrong, but here she is with a badly burned preschooler and milder burns on her own hands where she beat out the flames on my sister’s dress. This and other lesser incidents where she felt on the defensive for her use of sCAM really made getting her to listen to SBM/EBM hard. Anything that a doctor or her kids (one of whom is married to an MD) said which was perceived as an attack on her woo really distressed her.

        I dunno what would have helped her see the light sooner–but I do know that what she perceived as disdain, dismissal, and the like helped tip her deeply into the woo. I know there’s more efforts to get medical professionals to understand how their communication skills (and lacks) can so deeply affect patients, and I’m glad for it.

        1. Andrey Pavlov says:

          Brew:

          I definitely understand where you are coming from. I believe your story lays more on the side of mean-spiritedness, rather than poisoning the well (although yes, you can poison a well through mean spirit). I take poisoning the well to mean intentionally making statements or actions that make an entire category unpalatable, even if that is unjustified. Peter said both things – mean spiritedness and well poisoning. I agree fully that the former is completely inappropriate and I would never handle a situation like you describe in even remotely a similar manner. Offhand, my approach would be more along the lines of “Thank you for coming in. I see you’ve already tried helping the problem and it was really good and laudable you recognized you could use some more help. I’m happy to take care of this, and also tell you about some better ways to handle such things in the future and why this way is not the best. That way you may be able to handle such things more on your own in the future” Or something like that.

          But I don’t get what Peter meant by well poisoning given the context – he separated that from mean spiritedness. If the two are the same, then sure, I agree. But I have a feeling he intended to mean that even a well meaning, gentle, and informative discussion that demonstrates evidence against [insert CAM] is well poisoning, which I disagree with. Not being sure, I asked for clarification.

          1. PMoran says:

            Andrey: “But I don’t get what Peter meant by well poisoning given the context – he separated that from mean spiritedness. If the two are the same, then sure, I agree. But I have a feeling he intended to mean that even a well meaning, gentle, and informative discussion that demonstrates evidence against [insert CAM] is well poisoning, which I disagree with.”

            Mean-spiritedness might include such matters as not recognising that Dr Katz and even many alternative practitioners mean their patients well — they are genuinely trying to help them as best they can.

            Observe that the SBM response to Dr Katz is to try and cut the ground from under his feet, rather than offering constructive advice or solutions to problems that many other doctors are faced with and trying to deal with in ways that we also deplore.

            I contend that none of them are entirely happy with having to go outside of science, or to use placebos, or dabble with CAM, or deceive their patients in little ways. If there were better science-endorsed answers to the problems they face they would unquestionably use them. Holier-than-thou-ness may thus be a form of mean-spiritedness.

            By “poisoning the well” I mean being overly discouraging (which is also going beyond the reach of science) with patients with unresolved symptoms when they express interest in trying out a dubious but reasonably safe treatment option.

            In my view we are not obliged to officiously push scientific viewpoints if it means denying patients the possibility of even minor placebo influences or sound non-specific advice from alternative sources, or the satisfaction of being able to “do something” rather than the dissatisfactions of helplessness and frustration. Sure, the “alternative” will often not help at all, but that may in itself help the patient towards an acceptance of their state and of conventional support, and into working out how to live with it, having now had the satisfaction of trying out many or most of the methods that immediately suggest themselves.

            We can be non-committal — “some people think it helps them’ (implied personal doubt, that the patient can explore if wished — good doctors learn to read patient signals so as to guide their approach ).

            There is no reason why similar thoughts should not apply to our public utterances. There it is wise, simply for the sake of scientific accuracy, to allow that people may indirectly benefit from such methods through placebo and other non-specific influences (with subjective and psychosomatic states mainly). The unqualified “Homeopathy doesn’t work” is potentially “poisoning the well”.

            1. Harriet Hall says:

              “I contend that none of them are entirely happy with having to go outside of science, or to use placebos, or dabble with CAM, or deceive their patients in little ways.”

              I contend that they don’t “have” to do any of those things; they can offer comfort measures to patients, and even experimental or untested treatments, without misrepresenting the evidence or the purpose of the treatment, without deceiving their patients in any way.

            2. Andrey Pavlov says:

              Mean-spiritedness might include such matters as not recognising that Dr Katz and even many alternative practitioners mean their patients well — they are genuinely trying to help them as best they can.

              This is a straw man Peter. I have never said such a thing. I dare you to find a quote or prove that I even remotely hold such an idea. Same goes for the others here, Dr. Gorski and even Windriven included. I have stated that some practitioners are predators and have only their own interest at heart. That is undoubtedly a small minority.

              Observe that the SBM response to Dr Katz is to try and cut the ground from under his feet, rather than offering constructive advice or solutions to problems that many other doctors are faced with and trying to deal with in ways that we also deplore.

              This is twofold wrong.

              Firstly, go read my responses to Dr. Katz. You can read it over at the blog where I originally made them here or reproduced in full in the comments on this post. You cannot characterize my response to him the way you just have.

              Secondly, you are once again making the implicit assumption that we are taking away something that is there. We are not. We are pointing out that there is nothing there in the first place. You can’t cut the ground out of from under someone if there is no ground in the first place. You are accusing us of stealing his unicorn.

              By “poisoning the well” I mean being overly discouraging (which is also going beyond the reach of science) with patients with unresolved symptoms when they express interest in trying out a dubious but reasonably safe treatment option.

              I agree with you on this in principle. The problem is that this is a subjective measure. One which we here feel you are too far on. Which, once again, takes us right back to your entire argument being nothing more than kvetching about tone.

              In my view we are not obliged to officiously push scientific viewpoints if it means denying patients the possibility of even minor placebo influences or sound non-specific advice from alternative sources, or the satisfaction of being able to “do something” rather than the dissatisfactions of helplessness and frustration.

              Then we fundamentally disagree. My view is that we are under no obligation to entertain the fantasy and magical thoughts of anyone at any time*.

              But you are also drawing a false dichotomy – exactly as Katz is doing. It is either entertain CAM bull$hit or do nothing. There are many options that do not involve magical thinking at our disposal, many of which have been discussed. I would gladly advise my patient with chronic pain to get a massage and take time to relax. I would not advise them to see an acupuncturist to trick them into the same non-specific effects with needles.

              We can be non-committal — “some people think it helps them’ (implied personal doubt, that the patient can explore if wished — good doctors learn to read patient signals so as to guide their approach ).

              This is not unreasonable. And there are times when I have been (and I would be willing to bet every author here as well). But you seem to want to take it too far and be so purely frequentist and methodolatric (I invented another word!) that it becomes against the science as well. Don’t forget that the idea of SBM is to employ a Bayesian framework. Being non-committal as you suggest is, in very many cases, just as deviant from the science as being overly certain. You are choosing to selectively ignore evidence of a lower hierarchy that should inform your discussion with the patient so that you can remain non-committal. This is just as equally not in line with the science.

              There is no reason why similar thoughts should not apply to our public utterances.

              Yes, there is. And the fact that you still cannot see this leads me to believe there is no hope in these discussions. To be honest I have them more as a sounding wall for myself and to put them out there for others to either benefit from or critique as appropriate.

              There is a vast and fundamental difference between a patient-physician relationship and a public image. And, as you can see, being non-committal and just plainly laying out facts without adding import to them leads to lunacy like an herbalist clinic at the Cleveland Clinic, Reiki and reflexology offered at the Memorial Sloan-Kettering Cancer Center, and my very own professor in medical school lecturing us that personality affects not only which cancers you are likely to get but which treatments are likely to help you.

              Tell me Peter, honestly. Do you really think it is appropriate to lecture medical students that these ideas are scientific fact? And yet it is happening at one of the Sandstone Universities in Australia.

              But maybe you’re right. Continuing to ignore such things and merely laying out our facts on the table and walking away to let people decide amongst themselves could fix that problem.

              The unqualified “Homeopathy doesn’t work” is potentially “poisoning the well”.

              No. It isn’t. Not even remotely – and this is exactly why I made the comments that I did, because I had a feeling you would say something like this. Homeopathy doesn’t work. It cannot work. The entirety of science would turn on its head if it did. Everything about homeopathy except homeopathy is what “works” in your view. And even then, it doesn’t work all that well and is nothing more than a shoddy patch, a trick to deceive your patient. If homeopathy “works” I’ve got a teleportation device I’d like to sell you.

              But the real point – and I cannot fathom how you do not appreciate this – is that the quacks, charlatans, schysters, true believers, and everyone in between thrive in the tiny uncertainties of science. You’ve heard of the “god of the gaps” idea? That is where these bad ideas, including that minority intentionally exploiting them, live. And they are harming not just our patients but other poor sods who, for any of myriad reasons, end up believing in their claptrap. These ideas feed on uncertainty – it is their lifeblood. And the only possible solution is for science to stop being so overly humble and step into the light and be proud of its accomplishments. For most of our existence it has been second banana to magical thinking. And not at all unreasonably so, to be honest. But that era is over. It is time to actually make it be over.

              Because no matter how ridiculous, you can always push those goalposts further and say that I shouldn’t be dismissive of the guy who claims he teleported to the moon and back instantaneously. You know why? Because that would actually not violate any physical laws. It is absolutely 100% technically possible. But I am still not going to believe someone who claims it any more than I am going to say anything more than the completely accurate statement “homeopathy does not work

              *The nature of our business means there will inevitably be presented to us many extreme situations of such a unique nature that this rule will be broken many times in our careers. The key though is that the rule is broken rather than it doesn’t exist. I cannot, in good conscience, default to turning a blind eye as you suggest. I believe that harms the patient-physician relationship and that there is ample evidence to support that claim.

      2. PMoran says:

        Andrey: “Well, I agree… sort of. From my point of view, however, being a strict “EBM specialist” is not at all limiting in the manner you imply and explicate. ”

        Then there is little point to further dialogue. Let’s talk again after you have had more experience of general medical practice.

        I can be sure of that which I speak simply because SBM constantly laments some of the consequences of doctors having limited evidence-based options with many common conditions (often without showing any interest in the why of it). I have listed some of these consequences above.

        Thus, the only answer to Dr Katz so far (apart from MadinsonMD , who I think understands the problem to some extent) is more of that which provokes these unintended consequences : encouraging certain expectations in both our patients and ourselves as to the level of care people can expect from us, while restricting treatment options and putting what amounts to “I am very sorry, and will carry on seeing you if you are prepared to keep coming back, but you will have to put up with these symptoms” in its place.

        You say you have other things to offer, but without specifics for the kind of doctors at whose door these problems usually stop. Hospitals and most specialists naturally find it easier to stick to strict versions of EBM.

        1. Andrey Pavlov says:

          Then there is little point to further dialogue. Let’s talk again after you have had more experience of general medical practice.

          Well at least you weren’t condescending when you pulled rank on me this time.

          And I agree. To an extent. Yes, I have not been out in clinical practice. That could very well change my understanding and estimation of things. I recognize that and reserve the thought in my head.

          However, a few points to note. I have spent extensive time in direct patient care, even as a student. On the general wards I was carrying as many as 7 patients, entirely on my own (normally interns carry 9 where I am). I would come in, see them, write my own notes, my own orders, and then meet up with the team and present to the attendings. I set my own schedule based on how much time I thought I needed, completely independently. And I stayed until the very end of the day, every day. It was uncommon for an attending to feel my notes were insufficient or my orders needed revision. In clinics, I also saw my own patients. I would go in, do everything, go to the next patient, and the attending would come in behind me and check up on me. I scheduled all my own follow ups and had my own regular patients. In the ICU I carried 2-3 patients entirely on my own in the same manner. I also performed all the necessary procedures (central lines, bronchoscopies, arterial lines, etc), I spoke with the families, I even led a few family meetings (all with the attending present, of course). Even on my surgical rotations I was closing, sometimes by myself, I was co-surgeon and lead surgeon (including being lead on an emergent bilateral craniotomy for drainage of a subdural). And so on.

          The medical student education here in the US is very different to that in Australia. I know this quite well because I did one rotation back in Australia and have many Aussie friends in the program as well. I did more hands on clinical work in a week here than I did in 8 weeks in Australia*. They love coming out here to rotate because of how much more hands on experience and direct responsibility you get. And I did much more than the average US student because I wanted to, I worked hard, and I demonstrated my competence. My evaluations consistently read something along the lines of, “already functioning at the level of an intern.”

          I write all this not to brag, but to establish that I believe I have much more experience in general medical practice than (I believe) you are giving me credit for. And I still recognize that my time will be constrained and limited much further as I progress in my training and career. But, I’ve had the opportunity, many times, to utilize that “other hand” regularly with my patients and I have seen their responses. I’ve told people asking me about CAM (which, depending on the service, happened as often as daily but usually just a handful of times a week) exactly the truth. I’ve advised people to take care of themselves and relax, or have a hot bath, or do something enjoyable with their partner. I’ve found no limitations as you describe and had extremely favorable responses to date. All whilst sticking ardently to EBM.

          I can be sure of that which I speak simply because SBM constantly laments some of the consequences of doctors having limited evidence-based options with many common conditions

          But the thing that, in my opinion, bolsters my thoughts even more and is contra to your statement here is that others who have had that further experience in general medicine agree with me. Others here, notably Dr. Hall who is roughly of your generation of physician, but also others such as MadisonMD and Dr. Gorski. And not just around these parts but in person as well – my attendings, my mentor (who also happens to be my PI), and even my stepfather who happens to be a practicing intensivist for about 30 years. I am also older than most interns and spent 3 years working in a Level 1 trauma facility emergency room before starting medical school.

          These are not merely thoughtless idealizations of a fresh faced medical student. Nor ideas that are entirely my own. I am happy to shamelessly steal great ideas from where ever I get them.

          And additionally, your experience – just like anyone else’s – is useful, but doesn’t count for all that much. And the data also support thoughts on the matter. As usual the data informs my thoughts on the matter. Which is why I actually am a little baffled and affronted that you have been trying to argue that someone would say that relaxation, de-stressing, distraction, and rejuvenation by any means (whether it be by hot bath and candle light or a movie out with your partner) is not supported by EBM as a useful intervention to recommend. It is. That is, as you oft point out, precisely why some of CAM has some genuinely salubrious effects. The key is to harness those effects without lying to your patient. Which is imminently possible and vastly preferred to lying to them through CAM.

          (apart from MadinsonMD , who I think understands the problem to some extent)

          And this is how I know you are still, at least in the back of your mind, pulling rank on me. Treating me like the lowly med student or intern who should listen to you, the seasoned attending (consultant), and you have nothing to learn from me. Because what MadisonMD has said in the last day is precisely what I have been saying all along. Many times. That’s not to say he is learning from me, but merely that good evidence based ideas should be apparent to those who follow the evidence and think critically. But because he is an attending, he doesn’t get the short shrift from you that I do**.

          I’ve blathered on long enough and today is a busy day. I have to drive an hour to go do some paperwork for my medical license, run errands, clean house, and pack since I am flying back home tonight. If I’m lucky I’ll have some time to read and comment later this afternoon, but probably not until my flight. But I can’t resist this:

          You say you have other things to offer, but without specifics for the kind of doctors at whose door these problems usually stop.

          Because, Peter, those effects and actions are non-specific. That very same term you bandy about regularly. There are general concepts and a few solid specifics, but for the most part it is about finding the best way to communicate that to and make it work with your specific patient. Sometimes that’s a well timed joke, sometimes its a hug, sometimes it is just a hand on a knee and silent listening for 5 minutes. One of the things I do – consciously and actively – is talk to my patients like they are actual people and assume they can understand complex medical topics. I never talk down to my patients and I explain complex ideas to them. I once explained what AUC is and why it mattered to my patient’s diabetes management – an individual who never finished secondary school. My attending thought I was crazy and wasting my time. Until the next day he explained AUC and why it mattered to his diabetes management. I had just empowered him to take more control of his condition and understand better why we were telling him to take certain pills. And when he came in and asked about cinnamon pills to help with his diabetes and I told him it was almost certainly a waste of his money, want to guess his reaction?

          Yes, that is much harder to execute effectively as it is always contextual and requires constant attention, active thought, and extra time which is probably a good part of why many physicians don’t do it. But I’ve admitted – without hesitation – that there are myriad reasons it isn’t done. What I disagree with is that it is not doable in principle.

          1. PMoran says:

            Nevertheless, our further dialogue is pointless. While you are basing your opinions on your own experiences and your selected opinions among others, even later dialogue may not be more fruitful, because of all the influences that may still be operating within your area of experience : patient selection and self-selection, biased patient responses, our own confirmation biases and our own normally inflated regard for our own opinions — we only see what we expect to see.

            That there is an as yet unresolved problem for EBM/SBM to face is shown by what doctors are actually doing. SBM is responding to this in a stereotypical manner without actually thinking about realistic solutions, I suggest.

            I have no problem with SBM and general scientific scepticism continuing to try and compress medicine into an evidence-based shell. That is a good and logical trend. There can also obviously be little compromise when it comes to serious illnesses having highly effective treatments.

            We simply have to understand some of the difficulties that this strategy poses within our own ranks, also that there will be a number of unintended consequences. For example, the more successful you are in restricting medicine to science-endorsed methods, the more patients will be turning to CAM and under conditions that pose substantial more risk.

            So there may need to be room for more flexibility than is suggested by the usual SBM rhetoric (e.g. “ALL of medicine should be held to the same standard”).

            There will also be competing objectives. The only way to reduce pressures upon doctors is to keep some kinds of patients out of doctors’ offices (that will happen naturally when it is no longer anticipated that doctors will prescribe something — they won’t often keep coming back, or pay, just to talk). That reduces opportunities to exert the psychosocial aspects of medicine that are being held out by some to be a substitute for non-EBM-endorsed methods.

            I suppose I am reasoning towards the notion that doctors should be allowed considerable flexibility, according to the inclinations of their clientele or of specific individuals. Might that not be all that Katz wants?

            .

            1. Andrey Pavlov says:

              Now who is the one offering no specifics of help? You basically just said “unintended consequences happen, sometimes bad stuff happens, and that’s what’s happening”

              For example, the more successful you are in restricting medicine to science-endorsed methods, the more patients will be turning to CAM and under conditions that pose substantial more risk.

              That is an unproven assertion, one for which I find the evidence lacking. And not only lacking, I believe that there is some (not overwhelming and not clear cut) contrary evidence.

              I suppose I am reasoning towards the notion that doctors should be allowed considerable flexibility, according to the inclinations of their clientele or of specific individuals. Might that not be all that Katz wants?

              Sure. Let’s just get rid of medical school, board exams, and let anyone call themselves a doctor and do whatever it is that pleases them. Those who want to practice real medicine can choose it. Those who want to see real medical doctors can. Those who don’t, don’t. Let’s make it all the wild west.

              While you are basing your opinions on your own experiences and your selected opinions among others, even later dialogue may not be more fruitful, because of all the influences that may still be operating within your area of experience : patient selection and self-selection, biased patient responses, our own confirmation biases and our own normally inflated regard for our own opinions — we only see what we expect to see.

              That cuts both ways Peter. And our own Dr. Hall has, on more than a few occasions, called you out on your incredibly pompous assertions and stupendous hubris in your own comments.

              1. PMoran says:

                “That cuts both ways Peter. And our own Dr. Hall has, on more than a few occasions, called you out on your incredibly pompous assertions and stupendous hubris in your own comments”

                – if that makes you feel better, Andrey. However, that you are inexperienced in medicine remains a matter of fact.

                Also Harriet’s concept of “comfort medicine” (for use when there are no solid evidence-based methods) is a response to the very pressures I am talking about.

                There are quite a few simple souls to whom it is incomprehensible that they would go to the doctor about a problem and not be “given something for it” (just as their parents always did whenever they were sick). It would be cruel to many of these to do otherwise and they will unquestionably feel better for having “something to take”.

                I am not herein talking about the kind of amenable population that you seem to think you will be dealing with for the rest of your life and this is also not the only reason why such an approach may be the best of several poor options.

                Harriet’s other suggestion of using “untested or experimental treatments” carries the possibility of as yet unknown serious side effects, but perhaps she is thinking of more desperate clinical situations, where that is of less concern.

                MadinsonMD also understands what I am saying, posing his own solution in the form of “dozens of plausible things without RCT”.

                I think doctors like Katz would prefer to be able to try “something plausible” before resorting to CAM, but there are never actually “dozens” of such options, and once you start using unproven treatments it is likely that overall effectiveness is going to be dominated by non-specific influences including those related to placebo use, and practicality is going to be profoundly affected by individual patient interests and inclinations. (For example, the “naturally” orientated, or those prone to get drug side effects, will never agree to trying an unknown pharmaceutical.)

                So, once having relaxed the grip of “working better than placebo” science, different guidelines might need to come into play, and profitably so. Why not, for example, use methods that recruit as many potential non-specific therapeutic influences as possible? Hands-on, recurring, interactive programs of treatment like massage and acupuncture come to mind.

                Although there is as much evidence for one of these as the other in terms of likely effectiveness (remember, as compared to “no added care” and after taking into account the potential adverse consequences that discouraging further treatment will pose with some patients) — the former is acceptable to SBM. The latter, which would be more culturally acceptable to other populations or individuals, is not .

                Now don’t get me wrong. I don’t too much mind this level of preciousness, based as it is on acupuncture’s greater guilt by association with pseudoscience, rather than any likelihood of significantly better patient outcomes, so long as we are frigging aware of it!

                If we are aware of it we will not be taking ourselves more seriously than we truly deserve, giving way to our own — well, pomposity and hubris . We will not be quite so officiously trying to lord it intellectually and ethically over colleagues who are doing their best to reach the same ends as we are, but merely through adopting mildly different perspectives and giving different weight to competing obligations.

                If we are more self-aware we will not be interpreting medical science through our own “beer goggles” so as to ensure it supports this righteous crusade against pseudoscience, rather than clarifying our understanding of some aspects of medical interactions including the phenomenon of CAM. (I thought this would be the direction of SBM when it started.)

                One reason for being a little more flexible than EBM/SBM normally permits is that even if these resorts do not work, they will eventually convince many patients that it is futile to go on chasing one unproven or dubious treatment after another. Many do describe how they came to be more respectful of the mainstream through poor results with CAM.

                I don’t care if a few get to think that “homeopathy works”. A lot of people always have, yet medical science has still been able to advance and operate without hindrance. A little more permissiveness will also defuse allegations of conspiracy and turf-protection.

              2. Harriet Hall says:

                “Harriet’s concept of “comfort medicine” (for use when there are no solid evidence-based methods) is a response to the very pressures I am talking about.”

                No, comfort measures are not a “response to pressures.” They have always been an integral part of good clinical medicine: “To cure sometimes, to relieve often, to comfort always.”

                “Harriet’s other suggestion of using “untested or experimental treatments” carries the possibility of as yet unknown serious side effects,”

                Of course untested treatments carry the possibility of unknown side effects! That’s why we do science. I think it was clear that I would only suggest them when there were no tested treatments available and when doctor was honest with the patient about the lack of testing and the possibility of risks. Patient autonomy calls for patient choice; but it should be an informed choice, informed by the best available scientific knowledge and by all the facts. It is condescending and paternalistic to simply say “some people think it helps.”

                Yes, I know it isn’t practical or possible to give every patient a course in the scientific method and read them all the published acupuncture studies, and few patients would want that. When a good doctor/patient relationship has been established and the patient can trust the doctor because he has seen a good track record of the doctor basing his recommendations on up-to-date science and good judgment, it will usually suffice to say “Some people have thought it helped them but science has shown acupuncture to be nothing more than a theatrical placebo.” Or “Yes, homeopathy ‘works’ but only as a placebo.” If the patient wants more information, he can ask for it (and he will ask if there is a good relationship with good communication). If he doubts the doctor’s judgment, he should probably be looking for another doctor.

              3. Harriet Hall says:

                “even if these resorts do not work, they will eventually convince many patients that it is futile to go on chasing one unproven or dubious treatment after another. Many do describe how they came to be more respectful of the mainstream through poor results with CAM.”

                Many more are reinforced in their belief that there is some magic treatment that they haven’t yet found, and they continue the wild goose chase until they die or deplete their savings. I think that is far more common than becoming more respectful of the mainstream.

              4. Lytrigian says:

                Dr. Moran, acupuncture is NOT a harmless anodyne. Have you ever tried it? I have. Piercing the skin with needles, sometimes deeply enough to draw blood, is NOT risk-free. Have you ever had an acupuncture needle placed so that it scraped a tendon? I have. That’s not “comfort medicine” in the least. it’s not medicine at all.

                One reason for being a little more flexible than EBM/SBM normally permits is that even if these resorts do not work, they will eventually convince many patients that it is futile to go on chasing one unproven or dubious treatment after another.

                Or wed them to it. I tried acupuncture on the recommendation of a friend, who would have sworn on a stack of Bibles that it helped with his asthma. Now I know why it appeared to help, and a plausible reason became clear to me about midway through my first session, and based on my experiences alone, even otherwise knowing no better, I wouldn’t try it again. But my friend? He’s convinced it helped him, and he continues acupuncture treatment to this day.

                It’s not a terribly interactive therapy, by the way. That you would characterize it that way makes me strongly suspect that you don’t have any personal experience with it.

                I don’t care if a few get to think that “homeopathy works”.

                But you should. You really, really should.

              5. Andrey Pavlov says:

                if that makes you feel better, Andrey. However, that you are inexperienced in medicine remains a matter of fact.

                And your condescension comes back. I’ll take a moment to remind you that everyone else here, with vastly more relevant experience, also disagrees with you and agrees with me. I’ll also toss a little back your way and remind you that you were an orthopod. One of the most joked about fields because of their inability to understand actual medicine. Bone broke. Must fix bone. What is asystole

                How’s it feel when the conversation degrades to that Peter?

                Also Harriet’s concept of “comfort medicine” (for use when there are no solid evidence-based methods) is a response to the very pressures I am talking about.

                Yep. A science based one. But nice dodge.

                There are quite a few simple souls to whom it is incomprehensible that they would go to the doctor about a problem and not be “given something for it”

                I suppose I hold people, my patients included, in higher regard than you. Those poor, simple souls, who just can’t grasp these hifalutin concepts you and I bandy around.

                I think doctors like Katz would prefer to be able to try “something plausible” before resorting to CAM

                [citation needed]

                Why not, for example, use methods that recruit as many potential non-specific therapeutic influences as possible? Hands-on, recurring, interactive programs of treatment like massage and acupuncture come to mind.

                Because acupuncture has many harms associated with it, from direct to the patient to indirect to the pseudoscience to incredible amounts of wasted time in research. Massage I have no issue with at all. Nor any other recruitment of non-specific effects in a science based context, without lying to our patients or exposing them to harm.

                The latter, which would be more culturally acceptable to other populations or individuals, is not .

                Because the evidence is only equivalent in your head and you are ignoring all of the relevant risks.

                We will not be quite so officiously trying to lord it intellectually and ethically over colleagues who are doing their best to reach the same ends as we are, but merely through adopting mildly different perspectives and giving different weight to competing obligations

                Unlike Peter the Great, whose opinions are are so perfect that he needs to inform every single contributor here how right he is and how blind and wrong we all are. But only I, the dumb and lowly intern, is even willing to engage your blathering anymore so you you can conveniently just talk down to me. Speaks volumes.

                One reason for being a little more flexible than EBM/SBM normally permits is that even if these resorts do not work, they will eventually convince many patients that it is futile to go on chasing one unproven or dubious treatment after another.

                [citation needed]

                Many do describe how they came to be more respectful of the mainstream through poor results with CAM.

                Nice way to twist reality to your own ends. Actually, they’ve been describing how they continued, dissatisfied with CAM, until they stumbled across SBM and were given the tools to understand it and stop wasting their time and money.

                A lot of people always have, yet medical science has still been able to advance and operate without hindrance.

                You speak as if the enterprise of scientific medicine is something so well established in history that this is but a minor blip on aeons of SBM edifice. For someone old enough to know it first hand you show remarkable lack of appreciation of the history of medicine.

                In any event, I’m over it. Your pompous condescension has left me in a bit of a sour mood. Be content that you are sooooo much smarter than everyone here, and that I am nothing but a lowly intern who can’t even match your Jedi skills and knowledge.

              6. Andrey Pavlov says:

                It’s not a terribly interactive therapy, by the way. That you would characterize it that way makes me strongly suspect that you don’t have any personal experience with it.

                Thank you for taking the time to point out other ways in which PMoran has missed the boat (and the point). I too have actually had acupuncture. Both from a “traditional” acupuncturist and from a former internist who did it as part of her medical practice. Both experiences were indeed minimally interactive. About 5 minutes of chat before each, followed by about 5-7 minutes of placing needles, and then you get to lay in a room by yourself for some predetermined period of time (apparently qi takes time to re-route itself), and then removal and leaving. But not before paying your bill.

                On more than one occasion I had a needle hit something that made me jump in pain. More often than not, it was not a pleasant experience, but usually not overly onerous either. Either way, I tolerated it because I was convinced (at the time) that it would be helpful and I was desperate for pain relief. It “worked” for a bit of time, but then the effects waned and I continued my search for relief. Shockingly, what ended up working was coming to a science based diagnosis (Ehlers-Danlos), losing weight and getting fit, and realizing that some level of pain will always be with me. I now seek out massage periodically and particularly when I have flare ups of my pain and have never been happier.

                Of course, Peter knows all this as I have related my story a number of times, but he mostly ignores it or cherry picks parts of it to fit his desired narrative so that he can continue to chastise us. Mostly on our tone, which is rich considering how condescending he is in his own comments.

              7. Andrey Pavlov says:

                When a good doctor/patient relationship has been established and the patient can trust the doctor because he has seen a good track record of the doctor basing his recommendations on up-to-date science and good judgment, it will usually suffice to say…

                I’ve been meaning to add something to my comments and keep forgetting but this seems like a good juncture…

                One other reason I cannot countenance the idea of doing as Peter says and merely saying “Some people say it works for them” is because I also must tell people they should trust me to do incredibly invasive, often dangerous, and typically scary things to them.

                Try and put yourself in the shoes of my ICU patient as I explain that I need to put in a central line or do a pleurodesis (I haven’t actually done the latter… yet). For both the patient and the family these are, unquestionably, frightening and often painful (though of course I try and minimize it as much as possible) procedures. And I must explain to them that I can puncture their lung, or cause bleeding that could kill them, or give them an infection that could kill or at least make them miserable and extend their stay, or even put their heart into a lethal arrhythmia which may also kill them.

                How can I, in good conscience, convince my patient that the benefits of the procedure in this case outweigh such incredibly grave risks when I will be so “loose” and “fluid” in my recommendations for other proposed “treatments” and turn a blind eye to CAM, letting them implicitly believe I am giving an endorsement? What if I do so with a patient who gets acupuncture, has a bad experience (for any reason), and then finds out that acupuncture is a placebo with non-specific effects? That patient would be fully correct to question my judgment. And now, by chance, that patient is in the ICU for some other reason and I am trying to explain why I need to put a giant needle in their neck.

                I also cannot fathom how Peter doesn’t seem to understand that because of the impossible-to-escape hierarchy of knowledge and power in the patient-physician relationship that there is no such thing as a non-committal and neutral response? A “some people say it worked for them” is the same as “it works” coming from us. To fail to recognize this is, IMHO, a failure to practice medicine properly.

                But what the hell do I know? I’m just a lowly intern.

              8. @Lytrigian says:May 9, 2014 at 10:26 pm
                “Dr. Moran, acupuncture is NOT a harmless anodyne. Have you ever tried it? I have.”

                You have a complex life and I’m sympathetic to your situations and concerns. If anyone states that life is not fair is fortunately isolated from all the chaos, trials and tribulations.

                I’m aware of a few concepts that are glossed over on this website due to it being closed and selective against outsiders. I hope this info will add to your knowledge and logic.

                Not hubris but knowledge, imagination and experience.

                C. Chan Gunn, MD http://www.istop.org/drgunn.html did all the leg work to help a lot of us in the alternative communtiy realize that Acupuncture, per se is NOT what everyone thinks it is. Once you separate out the mythology from the “procedure” you can see the raw science. This raw science follows all the known and unknown laws of nature so are “irrefutable.” So this is very close to absolute truth! You can juggle the words and definitions around but you end up back at the truth.

                Gunn makes this therapy simplistic, practical, easier, more predictable and fun. His view can also be used to linked all hands-on, manual and adjustment therapies of antiquity to modern scientific medicine. So one can visualize all these on a spectrum. Beginning with simple stretching, yoga, massage, Chiro adjustments, Active Tissue Release, Myofascial Unwinding, other hands-on manipulation options, Acupuncture and all of the various types, Intramuscular Stimulation, dry needling to finally hypodermic needling and various other hypodermic injections.

                The needle pokes holes thru the skin and cuts or tears tissues which ignites the healing cascade. The needles also depolarized a contracted spastic tense muscle which allows the muscle to rest, reboot or unlock. Tadaaaa!

              9. Lytrigian says:

                @Dr Rodrigues

                This raw science follows all the known and unknown laws of nature so are “irrefutable.”

                No real science is irrefutable.

                Gunn makes this therapy simplistic, practical, easier, more predictable and fun.

                I’d rather it were true.

                His view can also be used to linked all hands-on, manual and adjustment therapies of antiquity to modern scientific medicine.

                I hope you realize that any theory claiming to be the One True Explanation of any diverse set of phenomena needs some VERY good experimental data behind it. Please provide citations of what must be the very numerous peer-reviewed studies in reputable journals supporting Dr. Gunn’s therapy and explanation for efficacy, showing specific effects above placebo.

                And do I understand from this that you would recommend acupuncture for pain management only, and not the range of conditions which acupuncturists purport to treat?

              10. @Lytrigian
                My job is to show you the way. I can not prove anything to you especially with a few references. I have posted them in the past. follow my thread or my links.

                As you go thru your journey please feel free to ask questions.

                If you want medical advice this site is not the place to ask, try HealthTap.

              11. Lytrigian says:

                @Dr Rodrigues — No, I was not asking for medical advice. I was asking what conditions you think acupuncture can treat.

        2. Andrey Pavlov says:

          Forgot to address the asterisks in my comment:

          *For those who do not know, this difference in education at the student level is not a reflection of different ultimate competencies. It is a reflection of the system in place in Australia. At the finish of their schooling they continue on and do a general rotating internship, followed by what is called “Junior House Officer” and then “Senior House Officer.” This is before being able to enter a specialist training program (and specialist includes GP or internist). Some people can shave a year off and some add a year or two. The point is that unlike in the US, where we enter specialist residency immediately after graduation, the Aussies have an extra couple of years to learn and practice the things that we must learn in only 2 years, hence the difference in intensity of training and direct patient care. This is, of course, a general description and there is ample variation. The merits of each system can be argued either way, I believe.

          **And yes, there is also history we have that lends to that. I am not blind to it, nor my own contributions to it. But it is unquestionable that there has always been the “attendings teach students, not learn from them” attitude from you towards me.

        3. Harriet Hall says:

          “Hospitals and most specialists naturally find it easier to stick to strict versions of EBM.”

          You are saying two different things. The fact that doctors find it easier to stick to strict versions of EBM does not mean that EBM prevents them from offering comfort measures to patients. It only prevents them from misrepresenting comfort measures as scientifically proven treatments that will cure or alter the course of illness.

  21. Joelle says:

    I actually came across a very lengthy article that you wrote about Dr. Andrew Wakefield. I was mortified at how you crucified him, but then again “the lady doth protest too much” right?
    I was just wondering if you had any intention of retracting your article (since it still appears on the web), and updating the information to reflect the recent studies showing that Dr. Wakefield was actually correct all along!
    I also wanted to give you a perspective as a parent that is living on the front lines of autism. I am the mother of a child with autism. Prior to conceiving this child, I went in for a complete physical to ensure that I was in perfect physical condition to have another child (I already had two beautiful, healthy children). This time around, my doctor told me that I needed an MMR vaccine. I was curious as to why when she explained that I had no rubella titers and if I were to contract rubella during my pregnancy, my child would be born with all kinds of horrific birth defects and possibly even stillborn. I was terrified. I immediately agreed to the vaccine. AFTER being injected, it was explained to me that I needed to wait at least 3 months prior to conceiving. I was outraged! Why wasn’t this part of it explained to me PRIOR to giving me the vaccine? When it was explained, something just did not sit right with me at all. I was told that if I conceived too soon after being given the vaccine, that my child could potentially suffer all of the terrible things that she told me he might end up with had I contracted a natural case of rubella during my pregnancy. Somehow, I felt I had put something into my body that was not previously there and that also posed a significant risk to my soon to be developing fetus! I was told to wait 3 months, I waited nearly 5 months, and then became pregnant. I did not think again about the MMR until my son was diagnosed with autism in 1998. The reason I began thinking about it again was not because of any study that was published, but rather because my son had recently been given HIS MMR. Interestingly, they waited until he was a year old before giving him this vaccine, when I asked why it was not part of the earlier schedule, it was explained to me that mother’s antibodies are so strong that they sustain the infants immunity for the first year of life and since measles is a normal childhood illness, many mothers of my age were exposed to them as children and therefore had strong natural immunity to pass on to their child. I said “ok, but all of the other vaccines are given early….some as early as the first day of life?” (The hepatitis B vaccine and WHAT is the RISK factor for a newborn contracting Hep B?? ZERO!) It was explained to me that with the MMR, if the vaccine is given too soon and interacts with the immunity provided by mom, the child could develop “issues” as a reaction to the vaccine because basically, they would be overdosed, to put it simply. So, his first birthday passed, and he was an amazing child. He reached milestones much earlier than his siblings and was talking well by this time. And then he was given his MMR vaccine. The following day, after a night of fever and screaming, his language started to sound funny. “Mommy, Daddy, Bye-Bye, and car-keys” began to sound like “Mom, Dad, Bye, Car”. Then the next day “Ma, Da, Ba, Ca” then the next day “Mmmm, Dddd, Bbbb, Cccc” and then….I would not hear the sound of my child’s voice for another two years. Two years of the worst hell any parent with a normal, healthy child should have to face. He was diagnosed with autism about 10 months later, after I was finally able to convince his doctors that something was happening to my child. He began looking at things from the side instead of straight on, his eye focus seemed to come and go, he began getting lost in a world where I could not reach him, where the sound of his name earned no response, where even his siblings who were constantly in his face could not pull him out of his world and back into ours. Over that course of time, the happy, bright, alert baby that I had given birth to turned into a completely different human being. It was terrifying to watch and not be able to do anything about. Because this began happening to him IMMEDIATELY after he was given the MMR vaccine, I began to research information on my own. I called my ob/gyn and asked them if they could tell me what my titer level was while I was pregnant. Certainly they could, they drew blood every month during my pregnancy. It turns out that my titers were 320. I asked what they needed to be to be considered “immune”, I was told that immunity is achieved with a level of 5. FIVE!?! My infant was marinating in rubella titers. He must have been born with a level that would have lasted him his natural life, but, instead of performing a 5 minute test to check for titers PRIOR to vaccinating children, they just gave him the vaccine…because vaccines are ONE SIZE FITS all and no one is willing to consider other options because we would not want to cause hardship to the financial gains offered by the vaccination program! Not ALL people should be vaccinated, sir. Some people have reactions so adverse, it costs them their lives. These reactions, sometimes known as SIDS, are never investigated, just shrugged off that there was something so wrong with the child they just DIED! Some children have severe life threatening allergies to eggs, a medium in which vaccines like the DPT are cultured, these children, when given that vaccine go into anaphylactic shock, which is why there is always a vial of epinephrine in the cabinet when children are vaccinated, just in case! But parents are not given ANY of this information and you are online saying that Dr. Wakefield is the monster? Please!
    The reality is that I was given an MMR vaccine prior to conceiving my third child. And then HE was given an MMR vaccine as part of his normal childhood vaccine schedule. The FACT is those two MMR vaccines CAUSED my child to develop autism when he was administered his vaccine. He was OVERDOSED with rubella antibodies and his body could not process the excess. The GI symptoms that this child suffered were horrific! His intestines had become permeable because his body was trying to rid itself of the toxic level of MMR antibody that was floating throughout his immune system. When I met Dr. Wakefield in 1998, he was the first person that could help me to understand what went wrong. Having that knowledge allowed me to begin helping my child, both to detoxify his body of what was poisoning him AND to move forward with behavioral therapy to address the damage caused to his developing brain. I was never a parent that told people NOT to vaccinate their children, but rather, I was a parent that told others to become informed, to ask that a titers test be run prior to having vaccines administered because its very possible that natural immunity is more than sufficient to take children beyond their first year of life. Maybe vaccines are something that can be put off until AFTER the immune system has had the opportunity to develop a bit, until AFTER the brain has had the opportunity to develop a bit. What’s wrong with that? I think the answer is not medically based, but financially driven, and you say Dr. Wakefield is the monster? I have since learned that I am a non-converter. I can receive an MMR vaccine every 6 months and within 6 months, I will convert back to zero. My body does not retain the titers, it eliminates them as quickly as possible. I wonder why the body was designed to do that naturally? Regardless, that’s the case for me and for my children, therefore, it is not in our best interest to be given these vaccines as we do not retain the titers but the other materials in the vaccine cause damage to our sensitive systems. It would cost about $5 for a titers test prior to the vaccine, and then a parent could make a decision that is right for THEIR child. People are individuals and any blanket system is going to have detrimental effects on many that don’t fit in to the “normal” range. It’s kind of like children that sadly die from a bad case of the measles. It’s quite rare, but unfortunately it does happen. What most people do not know is that a child that would die from a natural case of measles is also going to have a horrible reaction to the vaccine, which consists of the same stuff. It’s unfair to swing the data one way and then not explain that the exact same thing is going to happen on the other side of the coin. Anyway, I am not an unintelligent person and over the years, I’ve found it very offensive to be treated that way by the doctors and medical community that I’ve entrusted with the lives of my children. That system failed me in regards to my youngest child, it failed him and he will now have to pay for those errors for the rest of his life. Dr. Wakefield was sharing that information so that parents could make informed decisions. It cost him his career. I’ve watched the headlines blasting him over the years and now that independent studies have replicated his findings and found him to be correct, I would like to see similar headlines vindicating his efforts and, at the very least, for someone to step forward and apologize to this man for what you’ve all done to him, unjustly. Are you a person that can stand up and admit that you were wrong and apologize to him in front of the same community in which you crucified him? I hope so! Thank you for your time!

    1. brewandferment says:

      recent studies showing that Dr. Wakefield was actually correct all along!
      Citation needed

    2. Andrey Pavlov says:

      I would say that is unlikely. Particularly considering he was absolutely and unequivocally definitely wrong the whole time.

      Plus what brewandferment said

      1. David Gorski says:

        Hey, isn’t it good enough for you that Andy himself just proclaimed that he was right all along and that his results have been replicated? I mean, come on…

        http://scienceblogs.com/insolence/2014/05/07/andrew-wakefield-attracting-antivaccine-cranks-like-moths-to-a-fly-since-1998/

        1. Andrey Pavlov says:

          Funny that… I linked to the same thing. ;-)

    3. Windriven says:

      @joelle

      Seconding brewandferment, how about a citation to a reputable source saying Wakefield was correct? I’m not holding my breath because there isn’t one.

      I’m sorry to learn of your son’s autism diagnosis. But there is nothing in your meandering recitation that suggests your son’s autism was caused by the MMR vaccine. Your assertion that Wakefield has been vindicated, launched at the beginning of your comment and restated again at the end, is simply bullsh!t. This gives cause to wonder if you are a liar or just so ill-informed that you shouldn’t be allowed out of doors without a minder.

      So make me eat my words without benefit of Worcestershire sauce: cough up citations for credible confirmatory studies published in recognized peer reviewed journals. Or crawl back into your dank cellar of darkness, fear and misinformation.

      1. Windriven says:

        And thirding Dr. Pavlov…

      2. Tazia Stagg says:

        How did you decide that it was alright to resort to brutality in this situation?

        1. Sean Duggan says:

          That’s sort of Windriven’s default state, unfortunately… I think he’s right in his fundamentals, but his message is sometimes lost in how confrontational he gets.

          1. Windriven says:

            It isn’t my default state Sean, except when confronted with those whom I have cause to believe are trying to defraud others. I don’t much worry about the regulars here. They can take care of themselves. But for every commenter, every regular reader, there are untold multitudes of lurkers, here to read and to learn. I wouldn’t want them to think that there is controversy where none exists; a link between autism and MMR vaccines in this instance.

            My point in being belligerent is to either provoke them to defend their position so that it can be thoroughly dismantled – or to dissuade them from coming back with more clouds of innuendo and misinformation.

            I understand that my tone sometimes disturbs you. But sometimes it takes a rose to make a point, and sometimes it takes a hammer. The sCAMsters who appear here aren’t here for rational dialog followed by punch and a rousing sing-a-long. They are here to win hearts and minds.

            My default state is more like relaxed joviality as evidenced by a great many of my comments in these pages. But I have tremendous respect for the efforts of the bloggers here, for their time, their expertise, and their willingness to share their knowledge. When someone comes here spouting stuff and nonsense, especially when the tone is accusatory or belligerent, I put away the smile and the easy repartee.

            1. Sean Duggan says:

              I probably should have qualified that with that this is your natural state when someone comes in from a CAM point of view. I appreciate that the fight is difficult, and that it’s difficult to be civil when there are so many raving loonies out there, but you sometimes come off like a war vet who assumes that all Asians are enemy combatants because he’s fought so many of them. Thus, your message is lost in your method.

              1. Windriven says:

                I appreciate your thoughts, Sean. I’m not sure that I’m going to change. But I’ll redouble my effort not to eviscerate those who come to learn and contribute; only those who come to disinform, muddy and obfuscate. I have little patience for those and find little to recommend treating them as honorable and honored interlocutors.

              2. Tazia Stagg says:

                Thanks for the affirmation yesterday.
                This part was understood from context. (Normal people don’t need to exercise restraint or expect to get credit for being civil when no one is challenging them.)
                However, I’m not from a CAM point of view, etc., and he was eager to mistreat me, so today the excuse is less appropriate.
                I’d rather have such attitude and conduct as his among my opposition than in someone who (with respect to the topic at hand) agrees with me.

                Are you convinced that he appreciates your thoughts?

        2. Windriven says:

          “How did you decide that it was alright to resort to brutality in this situation?”

          Perhaps you and I have different definitions of brutality.

          To answer a related question, how did I decide that this person was a troll rather than a concerned parent:

          1. The comment was in a post unrelated to Wakefield/autism/MMR despite the fact that this subject is addressed with some regularity here;
          2. The writer used medically accurate terms like titer that the average soccer mom would not know;
          3. The writer salted the comment with a variety of wooisms right out of the autism crank playbook including a vague suggestion that MMR causes not only autism but SIDS;
          4. Opening and closing with the entirely false assertion that Wakefield had been exonerated by new proof showing his original research to be substantially correct;
          5. I have read these pages consistently for several years and do not recall seeing this nom de internet before. Yet here she (presumably) comes with a long, inaccurate diatribe liberally salted with all caps words throwing accusations rather than asking questions;
          6. She effectively called David Gorski a liar and a coward for writing untruthfully and failing to retract his alleged slander.

          I add it all together and figure this is some Age of Autism crank engaged in a propaganda attack. If I’m shown to be wrong I will man up, admit it, and apologize. But I have a crisp, clean $20 that says I’m not going to have to.

          1. Tazia Stagg says:

            You labelled that a dodge, so I stopped reading.

            Were you intentionally suggesting that I don’t understand the definition of brutality?

            1. Windriven says:

              “Were you intentionally suggesting that I don’t understand the definition of brutality?”

              Not really. But I do question your using it to characterize my response to “Joelle.”

              Now I might question your understanding of the word ‘labeled’ as in:

              “You labelled that a dodge, so I stopped reading.”

              Now it may be true that you labeled my response a dodge, but I didn’t label it at all. I didn’t agree with your characterization of my comment as brutal so I restated your question in a form worthy of a response.

              1. Tazia Stagg says:

                Try to tell the truth.

              2. weing says:

                The truth about your friend Joelle?

                “It is a tale
                Told by an idiot
                full of sound and fury.
                Signifying nothing.”

              3. Windriven says:

                “Try to tell the truth.”

                Deep comment there, Taz. I’m cut to the bone.

                I may have given you an unwelcome lesson in the meaning of the verb form of label and its conjugates but I don’t think anything in my comment could be labeled untrue.

                And look, you have your nose out of joint with me. Fine. Let’s have at it. But sniping at and kvetching about Brew, Chris, Simba, Ekko, Lytrigian, and weing and Frederick when you get around to it, is childish. They’ve made their points without particular piquancy. That makes you look like a tone troll. You don’t want to be a tone troll.

              4. Tazia Stagg says:

                I haven’t misused any words

              5. Windriven says:

                “I haven’t misused any words”

                Your assertion is counterfactual, your ‘arguments’ hollow and insipid.

                But.

                Fine.

                Whatevs.

              6. Chris says:

                Hey, I am waiting for a sound condemnation of my comment on homeopathy here. I am sure I ruffled some of Dr. Stagg’s feathers there.

                Though I am confused why a doctor of preventative medicine is so willing to defend someone who denigrates the value of preventing measles, mumps and rubella. That is just a bit strange.

              7. Windriven says:

                “Hey, I am waiting for a sound condemnation of my comment on homeopathy here.”

                Well you aren’t likely to get one Chris, ’cause you’re mean.

                And you know, I wondered about the doctor of preventive medicine thing too. Of course anyone can claim anything on the Internet.

              8. Andrey Pavlov says:

                I haven’t misused any words

                No, but you haven’t actually used any either.

    4. weing says:

      ‘recent studies showing that Dr. Wakefield was actually correct all along!”
      On what planet?

    5. Frederick says:

      I will add that, wakefield was not just wrong because it was wrong, but because he LIED, in invented his result out of thin air ( and also did unethical test to young kid that could have traumatize them, I say he tortured them ), totally, to make money.

      And Please next time you write a long post. make paragraphs, it will be easier to read thanks.

    6. Lytrigian says:

      I also wanted to give you a perspective as a parent that is living on the front lines of autism. I am the mother of a child with autism.

      Then allow me to give YOU some perspective as a parent that is living on the front lines of autism. I am the father of a child with autism.

      Indulging yourself by casting blame left and right, ascribing false causes to a difficult situation, does not make that difficult situation better. It does not help your child. Appropriate therapy and educational plans, attention to diet, and good, loving patient care from you are what will help your child. You owe it to him to be realistic.

      Actually contracting mumps, measles, or rubella, or pertussis, or anything else we vaccinate for would not have helped your child either, and would have harmed the community in which you live by elevating the risk for everyone. Refusing to vaccinate in the name of making yourself feel better, in the long run and when enough people do it, is bringing about the return of illnesses that have been under control for decades and were on the verge of eradication.

  22. brewandferment says:

    woops, didn’t mean to bold that…and also joelle, your comments are off-topic for this thread, which is about a completely different concept and doctor.

    1. Tazia Stagg says:

      It looks like you’re telling her to shut up.

      1. Chris says:

        No, just asking her to post a more relevant article. Perhaps one of these:
        http://www.sciencebasedmedicine.org/category/vaccines/

        I would request that she also post some actual citations, and use actual coherent paragraphs.

        And also to help defend Wakefield to provide documentation dated before 1990 that showed autism increased in the USA correlating to the use of the MMR during the 1970s and 1980. The MMR has been used in the USA since 1971, and is a much bigger country than the UK, If it did cause autism it would have noticed before Wakefield came on to the scene. Providing that evidence would show that he did not get his idea for his “research” by the huge pile of legal aide funds from UK taxes waved at him by Richard Barr.

        1. Tazia Stagg says:

          No?

          1. Chris says:

            “No” to what?

            Posting to one of the many articles actually on vaccines?

            That there is no data to refute that Wakefield cooked up data to provide “research” to lawyers to support a lawsuit?

            1. Tazia Stagg says:

              You wrote “No…” in response to my assertion that it looked like brewandferment was telling Joelle to shut up.

              By writing “No?” I was pointing out that your disagreement with my assertion wasn’t adequately supported.

              1. Windriven says:

                I think Tazzia Stagg confuses a polite request to honor this forum by staying on topic with an injunction to ‘shut up’.

      2. Ekko says:

        No, it looks like they don’t believe what she is saying.

        1. Tazia Stagg says:

          No?

      3. simba says:

        Which is what you do, gently, when people post off-topic posts, usually. Nothing personal. Just reminding them of internet norms, rather than watch them attempt to force the conversation to whatever they feel like talking about (‘derailing the thread’.)

        1. Tazia Stagg says:

          No.

          1. brewandferment says:

            ?? what are you trying to say with “no” in various comments, but nothing else elaborating upon it?

            1. Tazia Stagg says:

              Is that how you ask someone to elaborate?
              Are you a health care worker?

              1. Windriven says:

                “Are you a health care worker?”

                What does Brew’s employment have to do with anything?

              2. brewandferment says:

                yes…

              3. brewandferment says:

                No?

              4. brewandferment says:

                why?

              5. brewandferment says:

                Brevity of writing is an admirable trait…until it becomes so parsimonious that the thought being expressed becomes completely opaque.

              6. Chris says:

                Sounds like someone who has dealt with teenagers.

          2. simba says:

            What a substantive argument. Do you disagree with the entire concept of being off-topic? It would make a lot more sense to post the long MMR comment on an MMR post. There is no lack of them.

            1. Tazia Stagg says:

              Clarification: No, telling someone to shut up is not “what you do…”

              1. Chris says:

                So it is not okay to direct someone to post on topic, and that there are other more appropriate articles for her to address her concerns.

                That was not terribly clear.

                And it did seem obvious that asking for citations for her claims was not telling her to “shut up.”

              2. Lytrigian says:

                If I were at work and at a meeting about, say, a user request for a software change, and someone decided to blather on for 15 minutes about the air conditioning instead, telling them to shut up would be perfectly in order EVEN IF there was a problem with the air conditioning.

                That’s the equivalent of what Joelle did here, and you seem to think it’s a good thing. Thank God you’re not a co-worker of mine. You’d be insufferable.

              3. Tazia Stagg says:

                You’re both misrepresenting the situation.

              4. weing says:

                “Clarification: No, telling someone to shut up is not “what you do…””
                Don’t know what this means? Asking someone to show proof is not the same as telling them to shut up. Unless they don’t have the proof. I guess it would then be “Put up or shut up”

              5. Windriven says:

                “No, telling someone to shut up is not “what you do…””

                Ah the magic of browsers. So I did a global find on the word shut, the verb in the phrase ‘shut up.’ Guess where I found the very first mention?

                “Tazia Stagg says:
                May 7, 2014 at 1:15 pm

                It looks like you’re telling her to shut up.”

                Tazia Stagg posted that in response to Brew’s comment:

                “woops, didn’t mean to bold that…and also joelle, your comments are off-topic for this thread, which is about a completely different concept and doctor.”

                Lady, if you construe that to mean ‘shut up,’ you have serious problems. You might want to see somebody about that.

              6. Chris says:

                Yes, I am so terrible for actually providing a list of SBM articles that would be on topic for her comment.

                Then I ask for citations, and for her to make the comment more readable with paragraphs.

                And finally I asked for data that could prove Wakefield was not motivated by money offered to him by a lawyer.

                Specifically funds from the UK taxpayers to help families pursue legal redress. Wakefield’s research has incurred even higher expenses for the UK taxpayers during the recent measles epidemic in Wales, where about on in ten required hospital treatment.

              7. Tazia Stagg says:

                What an unpleasant group.

                “… You don’t have to be mean when you have a real point to make. In fact, you don’t want to. If you have something real to say, being mean just gets in the way….”

              8. weing says:

                “What an unpleasant group.

                “… You don’t have to be mean when you have a real point to make. In fact, you don’t want to. If you have something real to say, being mean just gets in the way….””

                How sweet of you!

  23. Mary Russell says:

    “My infant was marinating in rubella titers!”

    Classic.

    1. simba says:

      Honey and mustard is a much better choice.

  24. “The proof of the pudding is in the tasting – Katz endorses homeopathy and acupuncture, and I reject them. ”
    I’m amazed at how an academic can reject a therapy that I and many others use in our daily general medical practices. Gee, I think “Acupuncture along with all of it’s variations” is the most powerful medicine in medicine.
    If someone rejects a discipline that you know for certain (beyond doubt) has a definite scientific therapeutic effect on pain, one would have to wonder the intentions of that person.
    What are your intentions?
    Since SBM or modern traditional medicine is not 100%, how do we help those who fail a therapy?

    http://theness.com/neurologicablog/index.php/david-katz-on-evidence-in-medicine/#comments

    1. Lytrigian says:

      Gee, I think “Acupuncture along with all of it’s variations” is the most powerful medicine in medicine.

      Then frankly, sir, your thinking organ is out of order.

      Since SBM or modern traditional medicine is not 100%, how do we help those who fail a therapy?

      The first thing I would suggest is that a doctor not cast aspersions on a patient when a therapy doesn’t work, as you apparently want to. If a therapy correctly applied doesn’t work it’s not a failure of the patient.

      The second thing I would suggest is that, regardless of what else might be attempted, the placebos and magic you like to offer are not good alternatives.

      1. @Lytrigian
        Please provide the group with your definition of Acupuncture.
        Then define all of the variations of Acupuncture for the group.
        Then, maybe we can discuss your concerns, biases and beliefs.
        Please do not try to read my mind!!! That is kinda freaky.

        Did I say the “Acupuncture” was one of the best medicines in medicine?

        Who are you? What is your background? Who sent you here?

        1. Lytrigian says:

          Look, I quoted you exactly and commented on nothing but what you said. If the quote does not reflect your actual thoughts, the fault is not mine.

          The definition of acupuncture provided here http://www.sciencebasedmedicine.org/reference/acupuncture/ reflects more or less my understanding of it. Related treatments amount to other means of altering the flow of the fictional energy it purports to treat, such as acupuncture with the addition of electrical current, or moxibustion.

          I have no biases on the subject, and originally approached it with an open mind. My opinions are based on both extensive research of available sources, and on having tried it myself under the supervision of a highly reputable and universally recommended Chinese practitioner.

          My real first name is Chris, which I don’t use here to avoid confusion with someone else by that name. My last name is no one’s business but my own since I wish to preserve my privacy. I have a bachelor degree in Computer Science from an old, well-regarded East Coast engineering college, and have been a professional software engineer for close to 30 years. Despite being a gay man, I am the father of two boys, one severely disabled with cerebral palsy and the other coping with high-functioning autism, and I remain married to their mother in order to provide them a stable home. No one sent me here, and I read and comment on this blog of my own volition.

          1. Windriven says:

            Sorry to learn of your disabled son. The oldest boy next door when I growing up suffered from pretty profound cerebral palsy. No one – neither Michael’s parents nor mine – tried to explain any of what cerebral palsy meant to the rest of the neighborhood kids. Most of them thought it meant Michael was retarded. I probably thought that myself when I was younger.

            By the time I was a teenager I knew enough to know that Michael wasn’t retarded. I tried a few times to sit with him on his front porch and have some sort of communication but you know there was just no way that I understood to connect. Michael could just barely speak. In hindsight I’m pretty sure that he could understand perfectly well but I don’t think I appreciated that as a 15 year old.

            Many years later I heard a John Prine song called ‘Hello in There’ about old people who had become detached from the society around them. Made me think of Michael and the injustice of not having tried harder.

            Anyway, the point of this long-winded reminiscence is – and you probably already know this and I certainly don’t want to stick my nose in your business – it can really help to give those in the neighborhood some understanding of your son’s situation and some context in which they can relate to him. I certainly wish I’d had some guidance.

            1. Lytrigian says:

              Coincidentally, my son is also named Michael. He just turned 18, so right now I’m dealing with all the legal stuff — setting up a conservatorship for him; that kind of thing. He’ll need care all his life. We do try to keep him engaged, and he does understand most of what’s said to him and what’s going on around him, but he can’t speak at all.

              Fortunately, we live in a great neighborhood with fantastic folks on both sides of us. The only slight bump in the road was when, shortly after we moved in, a neighbor down the street came under the impression that we were running some sort of halfway house. Between the paratransit, and nurses and aides coming and going, I guess we must have looked much like that!

          2. Chris says:

            “My real first name is Chris, which I don’t use here to avoid confusion with someone else by that name.”

            Thank you, that is sweet. Though I do use an avatar that relates to a couple of my favorite things: math and gardening (I am reading a math book surrounded by roses). I started to use my first name years ago because there were those who did not like the version of my initials as a username: HCN. Which is how they showed up on a chemistry class roster with last name first.

            The last paragraph of your self-description makes you awesome in my mind. Your kids obviously make your life interesting by bringing you both great joy and interesting challenges. I have one with several medical challenges, and the other two just like to drive me nuts.

            1. Lytrigian says:

              Eh, we’re supposed to love our kids. It’s easy — natural, as it were. As I’m sure you know: you love them no matter how crazy they’re driving you.

              I hope you’re getting plenty of support with the medical challenges. It can be extraordinarily stressful.

              1. Chris says:

                Aargh.

                Though I can tell how weird Rochester, MN is… just because the oldest had his surgery there.

              2. Chris says:

                By the way, in a state with limited funds, it sucks when they say the now 25 year old kid does not qualify for their “developmental disability” department.

                It doesn’t help when dear spouse thinks he can get a job (he has only spent the last seven years getting a two year community college associates degree). I see us paying for some kind of health insurance for him next fall.

                Le sigh.

            2. Andrey Pavlov says:

              Those are some killer initials, Chris ;-)

              1. Chris says:

                ;-)

                Which is exactly what I thought when I saw my high school chemistry class list. So I used it on UseNet and got this lovely tribute:
                http://www.whale.to/a/hcn_.html

                Woo Hoo!

              2. Andrey Pavlov says:

                That’s almost as good as Jerry Coyne “winning” the Discovery ‘Tute’s award for “Censor of the Year” because he lambastes their idiotic ideas.

                Congrats!

              3. Harriet Hall says:

                Which is better, a poison or a laugh? My initials are HAH!

        2. Windriven says:

          “Who are you? What is your background? Who sent you here?”

          Steve, enough with that crap already. What is your obsession with who people are? Who they are isn’t important. What their thoughts and arguments are is important.

          When you ask who people are the thought that immediately comes to mind is that you can’t counter their arguments so you’d like to attack them personally. Beyond that, what do you want to know? Do you want to know that I went to a better school than you did? Well I did. But so what? That was 40 years age. I don’t use that to make the case that my arguments are better than yours. Your arguments and mine stand on their own feet.

          Finally, nobody sent anybody here. Well, Joelle probably. But that’s a different thread. Anyway, you sound like a bigger crank than you are when you hint at crap like that. We know you believe your acupuncture nonsense. We even know why you believe it. Suggesting that any of us is being paid or directed to challenge it is narcissistic and delusional.

          1. simba says:

            It’s pretty obvious it seems to happen whenever he has no argument to put forward. Otherwise it would be “Who sent you here… and your point are wrong and here’s why.”

            I felt kind of chuffed when I got it in response to my (pretty nonconfrontational) comments though. Who could I be working for? Big Flannel? A disgruntled trigger point researcher trying to drum up funding?

  25. Aubrey says:

    I definitely agree that alternative medicine that works is still medicine. Sometimes we just narrow things too much to what they can do and brand other insufficient ones as alternatives. The mistake of Dr. Katz is the way his arguments are laid out, and frankly the author of this post identified those loopholes. Now I think it’s not wrong to voice out opinions but to be ballsy enough to make a national publication your medium for it, I am astounded. Although the United States has some awesome healthcare in terms of advance treatments, the way it can make it more effective and reachable for masses is the reason why it’s not on this article that I found – http://www.uratex.com.ph/industrial_and_institutional/5-countries-best-health-care-system/. We ought to step up and make our advancements more accessible, or else the poor will only get poorer.

  26. PMoran says:

    “Dr. Moran, acupuncture is NOT a harmless anodyne. Have you ever tried it?”

    The overall cost/risk/benefit potential of acupuncture within medical systems is complex. You would have to take into account that patients whose symptoms settled under acupuncture (which will very often happen if only from natural remissions), might otherwise have developed serious side effects from drugs or form more invasive medical procedures.

    There is also no doubt acupuncture could be made safer by regulation. SBM eschews that, through the somewhat reasonable fear of offering it unmerited legitimacy. Perhaps that position is too reliant upon the hope that it will soon be persuaded it out of existence. Acupuncture has actually attracted a fee from Australia’s Medicare system for decades, without (that I can recall) serious harm to anyone, or any evident deterioration in the overall quality of medical care, or our country slipping back into the medical Dark Ages .

    “Interactive” was perhaps not the best choice of words but I had in mind the psychosocial interactions that are involved in having to get out of the house and engage with other people and practitioners, also the fact that the mere temporary distraction from symptoms from the needling (especially if “scraping along the bone” — not that I would advise that) may help adjust symptom-tolerance settings in the brain. Andrey still wants to dismiss the euphoria that he experienced after acupuncture as not having any significant therapeutic potential.

    One of my threads of thought is that it is presumptuous of us to yet hold that we fully understand all the processes that go on within complex medical interactions, and that may be contributing towards some of the results that people often report from CAM and that are also demonstrated in some kinds of study. We do not have to embrace pseudoscience to think again about such matters.

    1. Harriet Hall says:

      “it is presumptuous of us to yet hold that we fully understand all the processes that go on within complex medical interactions…We do not have to embrace pseudoscience to think again about such matters”

      We DON’T hold that, and we ARE constantly thinking again about such matters. You are the one who is presumptuous to suggest you are wiser than the rest of us, and you have become a very annoying broken record. Please, please, please, stop writing these comments and write that guest article we have been begging you for.

    2. Andrey Pavlov says:

      Andrey still wants to dismiss the euphoria that he experienced after acupuncture as not having any significant therapeutic potential.

      Yes. And I will dismiss the euphoria of faith healers, speaking in tongues, Indian sweat lodges, auto-erotic asphyxiation, the “high vibrational state” and euphoria of dolphin-human telepathic communication, the “peace” of speaking with a dead relative with the help of John Edward, and a whole host of other completely fake experiences that we trick ourselves into experiencing and believing as having therapeutic benefit.

    3. Lytrigian says:

      You would have to take into account that patients whose symptoms settled under acupuncture (which will very often happen if only from natural remissions), might otherwise have developed serious side effects from drugs or form more invasive medical procedures.

      I have very low confidence that any self-limiting symptoms which might be settled by acupuncture’s placebo effect would otherwise be treated by a drug or invasive procedure by order of any ethical evidence-based practitioner.

      I, for one, did not experience the euphoria you describe. Ironically, the breathing difficulty I thought I was experiencing was due to stress, as became clear one panic-attack induced visit to an emergency room later. So, at least for me, acupuncture didn’t even have the sort of non-specific effect promised.

      1. PMoran says:

        “I have very low confidence that any self-limiting symptoms which might be settled by acupuncture’s placebo effect would otherwise be treated by a drug or invasive procedure by order of any ethical evidence-based practitioner.”

        Backache, headache, migraine, osteoarthritis?

        ( I specified spontaneous remission of symptoms but placebo responses will occur in much the same conditions.)

        ( A recent study suggested that knee osteoarthritis tis is still often treated by laparoscopic debridement under general anaesthetic, despite evidence that it is of help in very limited cases.).

        1. Andrey Pavlov says:

          I have very low confidence that any self-limiting symptoms which might be settled by acupuncture’s placebo effect would otherwise be treated by a drug or invasive procedure by order of any ethical evidence-based practitioner.

          To which Peter responds:

          A recent study suggested that knee osteoarthritis tis is still often treated by laparoscopic debridement under general anaesthetic, despite evidence that it is of help in very limited cases.

          So acupuncture use is justified by data showing that physicians aren’t doing what they are supposed to do. Nor does it even remotely address Lytrigian’s point.

          Backache, headache, migraine, osteoarthritis?

          I would argue that the harm of acupuncture (which includes all the pseudoscientific baggage it carries) outweighs the harm of providing NSAID or even opiate treatment for these conditions. That is not an argument that can be clearly and easily settled by the evidence and is indeed more of a judgment call. However, MadisonMD did point out the discussion we had using rigorous data demonstrating that the actual effect size of acupuncture is rather smaller than Peter tries to claim it is, which makes it rather harder to make the claim he is (incessantly) trying to.

        2. Lytrigian says:

          A recent study suggested that knee osteoarthritis tis is still often treated by laparoscopic debridement under general anaesthetic, despite evidence that it is of help in very limited cases.

          Even if this were a valid example of something done by an “ethical evidence-based practitioner” — it’s not — it would be a tu quoque and no kind of argument at all.

          And if you’re seriously suggesting some kind of invasive procedure is normal treatment for migraines, then all I can say is that the world you live in is totally unfamiliar to me.

    4. I’m amazed at how well everyone thinks they know alternative esp Acupuncture. I have stated it many times “it is not what you think or know it to be!!”

      To someone who has practiced the discipline, I can say “Y’all are showing you are living in a blissful isolated world. Blissfully blind, biased, ignorant, pernicious and apathetic on your pedestals.

      Acupuncture and a lot of other alternative are valid therapies.

      A lot of orthopedic, treatments for headaches, incontinence, cholesterol, Reflux, Menopause, Alzheimer, dementia + others, I would consider malpractice.

      1. WilliamLawrenceUtridge says:

        I’m amazed at how well everyone thinks they know alternative esp Acupuncture. I have stated it many times “it is not what you think or know it to be!!”

        You’ve also persistently refused to state exactly what it is, and what is wrong with the acupuncture studies that consistently find no benefit beyond placebo effect. Functionally, we can’t tell the difference between you having some secret wisdom we are not privy to, versus you blustering about how great your results are in order to cover up the fact that they’re actually terrible.

        Acupuncture and a lot of other alternative are valid therapies.

        Then why do they consistently fail to show any benefit when tested properly? Why are they efficacious in your office, but as soon as you move them into a lab with a doctor who isn’t cheering about how great it is, it fails? Real medicine works whether or not you believe in it, why doesn’t this apply to acupuncture?

        A lot of orthopedic, treatments for headaches, incontinence, cholesterol, Reflux, Menopause, Alzheimer, dementia + others, I would consider malpractice.

        So what? You consider a lot of malpractice ideas to be good ones, such as using acupuncture and giving your patients financial advice. You rather miss the point – if you can’t point to reliable scientific evidence to support what you are doing, then what you are doing is about as justified as bloodletting or frontal lobotomies.

        1. I have given all the references, You have to do the reading and comprehension.

          Until then, yes you will not understand anything related to alternatives or complementary medicine.

          1. MadisonMD says:

            You provided links to a theory that is unsupported by evidence. There are plenty of contradictory theories in the world. There are plenty of ‘authorities.’ Science is anti-authoritarian. Truth is ascertained solely in what is supported by evidence. Even then there are disagreements.

  27. MadisonMD says:

    Andrey still wants to dismiss the euphoria that he experienced after acupuncture as not having any significant therapeutic potential.

    Oy, vey! We have been through the actual measured magnitude of acupuncture-placebo already.

    1. PMoran says:

      Andrey, you cannot invoke plausibility when it suits you and ignore when it doesn’t. The fact that patients do describe a great sense of well-being after the completion of “unlikely” treatments does contribute to the likelihood of significant, even enduring, influences upon some kinds of illness or symptoms.

      As I have pointed out to you and others whenever this has come up, the Hrobjartsson meta-analyses do NOT fully resolve the question of the potential of placebo influences, firstly because no attempts was made in those studies to maximise such influences, secondly because they give pooled outcomes that will obscure expected different responsiveness of different conditions, populations or individuals, and finally because they in no way mimic the conditions that may apply within CAM (or any other part of medicine) with amenable patients and a charismatic “healer”. Oh, and fourthly, if you believe that acupuncture is a placebo why not add on the usual extra small benefit from “real” acupuncture over sham?

      I allow that there is the problem of reporting bias, but even taking that into account the science does not back up the certainties framing our rhetoric.

      1. Andrey Pavlov says:

        Andrey, you cannot invoke plausibility when it suits you and ignore when it doesn’t. The fact that patients do describe a great sense of well-being after the completion of “unlikely” treatments does contribute to the likelihood of significant, even enduring, influences upon some kinds of illness or symptoms.

        I do not. But I – and the others here – seem to have a much better understanding of where that plausibility lay. The claim of great senses of well being is simply not as profound an indicator as you wish it to be. Something just about everyone here has tried to explain to you.

        As I have pointed out to you and others whenever this has come up, the Hrobjartsson meta-analyses do NOT fully resolve the question of the potential of placebo influences

        There are other studies besides H’s. Many of which were discussed, at length, by myself and MadisonMD. But if you keep wishing to focus so narrowly and doggedly, sure, you can fool yourself into thinking there is something more profound to be found.

        The rest of your argument is essentially that there are some people, in some situations, with some practitioners, with some conditions who will experience a profound benefit. Besides the fact that the same thing can be said for any of the other “profound experiences” I already said I would dismiss (and you don’t seem to be arguing for the therapeutic potential of getting people to speak in tongues and speaking to their dead relatives for some reason), the only reasonable action from that is to argue we should try and determine if that group actually exists, then how to identify them, then how many there are, and only then finally claim that acupuncture may be helpful for those people. Which, at the end of the day, is rather likely to be so few in such contrived circumstances it simply isn’t worth the effort (even if there were no additional pseudoscientific baggage).

        But no, you do precisely what is unscientific. You claim that in this lack of knowledge there must be some utility that we should recognize without appreciating the fact that this uncertainty is rather small and your “acupuncture of the gaps” exists in a very small gap to begin with.

        Oh, and fourthly, if you believe that acupuncture is a placebo why not add on the usual extra small benefit from “real” acupuncture over sham?

        Because the overwhelming majority of studies that demonstrate this are either very poorly done or have authors with an obvious bias. The exceedingly few that remain are simply overwhelmed by the many more that demonstrate no such thing. And only people with some bias or self delusion cling to that tiniest of footholds.

        I allow that there is the problem of reporting bias, but even taking that into account the science does not back up the certainties framing our rhetoric.

        Yes, it does.

        1. PMoran says:

          A:”There are other studies besides H’s. Many of which were discussed, at length, by myself and MadisonMD.”

          I must call this bluff, since H’s meta-analysis would have included all available studies purporting to compare placebo with “no treatment” arms. I eagerly await your advice as to which studies are you talking about and how they don’t also suffer from the flaws I referred to.

          A: “The rest of your argument is essentially that there are some people, in some situations, with some practitioners, with some conditions who will experience a profound benefit.”

          Unfortunately for medical scepticism this is precisely the hypothesis that CAM poses — mainly, of course, with subjective and psychosomatic complaints. And even H was unable to rule out “clinically significant” influences for pain and nausea.

          I have pointed out myself that without directly testing the matter out we cannot be sure that the same results would be obtained with the clientele of a typical Western medical practice.

          A: “Because the overwhelming majority of studies that demonstrate this are either very poorly done or have authors with an obvious bias.”

          You haven’t thought this through. Even if this were true, the resultant flaws mainly entail loss of blinding, which will enhance patient responsiveness to “treatment” (or reduce responsiveness if “sham” is sensed) — rendering my point valid that you should be combining he results of “real” acupuncture and “sham”, if wanting to try and measure total “placebo” potential in this system (actually it’s often placebo + a variety of additional non-specific influences but we in the sceptical camp prefer the negative connotations of the term “placebo” as a collective for all such influences — a more neutral term would aid this area of inquiry)..

        2. Andrey Pavlov says:

          I apologize but I don’t have time to adequately address this. I just got back from a semi-holiday in California and leave for a full holiday in Costa Rica tomorrow morning (spending a whole 9 hours at home between flights. I won’t be taking my laptop so I think it will be unlikely that I will be able to respond.

          If you remind me sometime in a week or two, I’ll try and take the time to respond.

    2. To understand what actually can cause or simulate an illness you must read Travell/Simon et al or you will (I did for 15yrs) get sucked in a traditional limited mechanical medical practice of poly-pharmacy.

      So yes, if you have not read or practiced all the authors of Myofascial pain and dysfunction you are practicing at less than optimal care — if I was to testify in court. You would get off because the of majority of MDs practice with this incomplete awareness.

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