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How to Build a Bridge

People tend to limit their reading to sources that agree with their beliefs. We find ourselves mostly preaching to the choir; our message usually doesn’t reach those who most need to hear it. I recently received an inquiry from a science-based medical doctor asking how to approach others in building a bridge to clarify so much misinformation.

My first thought was that you can build a bridge but the real challenge is persuading people to cross that bridge. Like leading a horse to water…

How to approach others? That’s a tough question. The best approach varies with the individual and with where he is in his journey. Confrontation seldom works: it just makes people angry. It is counterproductive: it only serves to make them invent more rationalizations to defend their beliefs. Although sometimes anger can be a good thing. I got an e-mail from an acupuncturist who was incensed by an article I wrote saying that acupuncture was not based on good evidence. He set out to prove me wrong by looking up the evidence behind what he had been taught by his teachers about acupuncture’s efficacy for specific conditions, and when he couldn’t find any, he realized that his teachers and his textbooks had misled him with lies. He gave up acupuncture and went back to school to learn a science-based health profession.

If someone has never had his belief challenged and thinks it a universally accepted truth, it might do some good to show him otherwise. When I was in the dentist’s office earlier this week he asked me what I thought about detoxification. I told him I thought it was a pseudoscientific concept with no scientific validity, that proponents couldn’t even tell you what those “toxins” were, much less measure how much had been removed, and that there was no evidence that detox objectively benefitted patients. He had me repeat this to his assistant who was currently doing a detox. She looked at me very strangely and I may have created an enemy for life. But just possibly I may have started a small crack in her certainty that might someday widen to let accurate information seep in.

Some people respond to accurate information. I belong to the Healthfraud discussion list on Quackwatch and we have had several people thank us for providing accurate information, debunking false information, showing the fallacies in arguments for claims, and helping them learn about the scientific process. They tell us they have discarded their previous false beliefs because of what they read there.

When I spoke at a local college I mentioned that diet supplements are not regulated like FDA approved drugs and have been found contaminated with everything from insect parts to prescription drugs, and that dosages sometimes vary wildly from what the label says. One older student got very upset and said she was going right home to clean out her cabinet and throw all those products away.

I have gotten e-mails from people who decided not to waste their money at the Amen Clinics or on treatments with the DRX-9000 spinal decompression machine after reading my articles.

Unfortunately, many people do not respond to accurate information. Some people choose to form strong beliefs on hearsay or personal perceptions or ideological grounds without any input from science. Scientific information is irrelevant to them so they are not likely to change their minds no matter how much evidence from scientific studies you throw at them. It is useful to ask people what evidence it would take to change their minds. True believers frequently say nothing would change their minds: they know they are right and they are sure that testing would only serve to demonstrate the truth of their beliefs. It’s a waste of time to talk to these people.

I met a believer in dowsing and I gave him a book explaining the ideomotor effect, showing that dowsers had never been able to pass controlled tests, and debunking dowsing in detail. We held a public debate afterwards, and what he said was as if he had never read the book. He managed to just ignore everything in it: his “pro” side of the argument boiled down to two points: he’d personally seen it work and lots of people believed in it. That was enough for him.

Then there are people who are capable of responding to new information but don’t want to hear it. Don’t confuse me with the facts; my mind’s made up. It’s more comforting to have a belief and stick to it than to deal with uncertainty.

Something I haven’t tried yet but want to: ask them if they know of something that doesn’t work but that some other people believe in. Once you find something they reject, you might be able to argue that logical consistency requires that their pet remedy be rejected on the same grounds. For instance, if they reject bloodletting to balance the humors but accept reflexology, you might point out that during the many centuries bloodletting was used, there were far more testimonials from patients and doctors than there are for reflexology today. So if they accept reflexology on the basis of testimonials, they should logically accept bloodletting on the same basis. If they reject bloodletting because science showed it didn’t work, they should look more closely at what science says about reflexology.

Humor can be effective in making a point, like the comedian who said “Of course science doesn’t know everything; it KNOWS it doesn’t know everything, otherwise it would stop.” And like Mark Crislip’s “Alternative Flight.”

The best strategy would be to guide people to discover the truth for themselves and claim it as their own, but I’m afraid I don’t have the patience or the psychological acumen to carry that out. It’s too bad Socrates isn’t around to help.

I am not foolish enough to think I could ever influence true believers; but even for them, it might be possible to plant a tiny seed of doubt that might be reinforced by future experiences and might eventually grow into a plant. Dripping water can wear away the hardest stone over time. But realistically, I can only hope to reach the fence-sitters: those who have not yet irrevocably made up their mind.

I hope readers will share their own success stories and bridge-building ideas in the comments section.

Posted in: Science and the Media

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80 thoughts on “How to Build a Bridge

  1. Jan Willem Nienhuys says:

    I have a little experience in earth ray beliefs. In 1932 a crazy German baron named Gustav von Pohl explained that the dowsing reaction is caused by earth rays, and those earth rays cause cancer. He sold boxes that offered local protection for earth rays. (When intrepid researchers opened such boxes, they were almost empty, except for some strips of iron, lead, copper etc.)

    Earth ray belief became very popular in Germany, and it still is, I believe. This superstition carried over to the Netherlands (after 1945), where followers of von Pohl sold many of these boxes, even to municipalities.

    One is reminded of government agencies using Quadro Trackers to detect bombs, weapons and drugs.

    The Dutch Royal Academy of Science (KNAW) investigated the whole phenomenon very thoroughly and brought out two hefty reports in 1954 and 1955. The believers didn’t give up their beliefs, but they gained not many new adherents, and for a long time earth ray and dowsing belief was not very prominent in the Netherlands. Of course the fact that dowsing for water is a rather useless activity in the Netherlands (wherever you dig, you reach water very quickly) contributed to this state of affairs.

    (Contrary to this, the German government commissioned around 1988 two credulous professors to investigate Erdstrahlen, payed them something like 200,000 euro, and got predictable results, i.e. a wishy washy document that implied that there might be something to it. When the German Skeptics performed a test under almost impeccable circumstances, with the help of a broadcasting company, it did not have much of a social impact.)

    Moral: if someone with a lot of authority says something is nonsense and backs it up with first rate research, it can make a difference.

    I have been contacted several times by people who thought they could detect earth rays, usually by detecting that some kind of protective device was on or off. In some cases they could also dowse for other things.

    1. A lady who thought a flat copper figure 8 (or something similar) could deflect earth rays. I explained to her that she could easily test that. The whole point was that she should ask the help of friend to hide (or not) the 8 at random in such a way that she herself couldn’t possibly know the location and/or presence, and then try to dowse. She wrote back to me that she had tried to do so, and to her surprise she had found that the whole effect was an illusion.

    2. An engineer whom I gave a similar advice. He rigged a computer to switch the protective device off or on. He wrote back to me that he was extremely surprised: if he knew the “random” sequence of off/on states he got perfect scores. But when he let the computer produce the randomisation without his knowledge, he got only chance scores.

    3. Another engineer with a similar claim received a similar advice, but I never heard of him again. I even don’t know whether he did the planned experiment.

    4. A famous French chemist, Chevreul, investigated the powers of the pendulum. He couldn’t figure out how it worked, and finally decided to do a blind test (his assistent had to organise the blinding and randomizing). He discovered that it was all an illusion. I don’t claim any involvement: Cheveuĺ (1786-1889) performed this experiment in 1812. In those times pedulums were supposed to make rotatory movements, and Chevreul later warned Ampère to be very careful with various claims about circular currents and circular force fields.

    Moral: even a good scientist can be fooled for some time, but a good scientist can also give up a belief, if his own experiment proves him wrong.

    4. A guy claimed he could use his pendulum to distinguish good wine from bad wine. I suggested that it should not be difficult for him to distinguish paint thinner from wine, and offered 2500 euro for a successful test. He refused, saying he had better things to do, such as curing people.

    Moral: if someone makes a living with some kind of nonsense, he or she will not easily change mind, and even avoid confrontation.

    5. A group of people let themselves be tested (1992) for their dowsing capacity by the Dutch organisation Skepsis. They had to find a ‘crystal’ or amulet in one of six closed boxes (the location was determined by the throw of a die). They all failed. They almost all had excuses. One lady accused us that we had hidden a powerful magnet under the floor (it was in the cellar of an old fortress). Another said the light was not good. A third one said that she was distracted by the floral pattern on the lids of the boxes. A fourth one said that the cotton used to prevent rattling blocked the dowsing influence. A fifth one said that the large heating pipes running through the cellar disturbed her. A sixth one conjectured that the boxes got contaminated by the dowsing influence. The seventh one shrugged and said it was an interesting experience.

  2. The scientific method is a thought process used in science to investigate, validate, and confirm natural phenomena. By using the scientific method, the results of one investigator can be reproduced by another investigator. Unfortunately, not everyone uses the scientific method. Therefore, to build bridges with those who do not, we will have to use other methods of rationalization. Unfortunately, these may need to rely on non-scientific methodologies such as emotion.

    Dr Sam Girgis
    http://drsamgirgis.com

  3. Gregory Goldmacher says:

    Dear Harriet,

    Lots to think about here, and thanks for your work once again.

    The comedian you mentioned is Dara O’Briain, and readers here should definitely look up his routines. The line that immediately follows his “science KNOWS it doesn’t know everything” bit is one I love to quote:

    “Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

    ~G

  4. Anthro says:

    Alas, I have had NO success and have ruined a number of budding friendships for my efforts. I am seen as “close minded” for only “believing” in science.

    I am currently proceeding very gently with a fence-sitter on the GMO topic, one I am not completely decided on myself, but am not opposed to for the non-specific, faith based reasons that my friend espouses.

    Thanks for the column, even though its conclusions are less promising than I’d like to hear.

  5. windriven says:

    Echoing and amplifying the comments of Dr. Girgis above, before anyone can be convinced of anything, before any exchange of ideas can occur, there must be at a minimum a common language. Most of the credulous individuals I have met (though certainly not all) lack rudimentary scientific literacy. It is common to hear from these that belief in science is equivalent to belief in any other system. Disabusing them of that misconception is a useful first step.

    I am far more perplexed by those who have – or ought to have – a thorough grounding in science. The Lizard of Oz leaps to mind, though there are plenty of others to compete with him. If one takes these apostates at their word, that is to say if one accepts that they believe unscientific nonsense, it begs the question of how they reconcile these beliefs with scientific evidence to the contrary?

  6. Pablo says:

    Re: Humor
    As usual, great post Harriet. A few years ago I published a satirical/humorous piece in BASIS (Bay Area Skeptics Information Sheet) on The Secret entitled “The Secret’s Secret: What, Me Worry?” I gave a copy to a fan of The Secret: a woman who cuts my hair. The next time I saw her, she couldn’t wait to tell me how hilarious she thought the article was and how she suddenly realized the silliness of the concept. Through humor, she was converted. She’s now a fan of Penn & Teller’s B.S. Although this is a single instance, as you stated, it’s clear that satire can also be an effective tool for making a point.

  7. Thanks for the observations Harriet Hall.

    I had an experience Monday that was similar to your bloodletting method.

    I had to have my mouth numbed at the dentist for a filling replacement. When the work was done, I asked the dentist how long it would take for the numbing to wear-off (he really went all out on that numbing). He replied, probably about an 1 to 1 1/2 hours. The hygienist commented that she had heard that drinking a caffeinated beverage made the numbing wear off much quicker and asked the dentist. “Have you heard that?”

    The dentist casually replied “Oh sounds like one of those things that doesn’t have any literature behind it, like not swimming for an hour after you eat. Remember having to wait around to swim? Where did they get that?”

    He was very non-confrontational and used an example that’s often joked about (around here at least, don’t know if that’s a national thing), but he got a point across. These myths or unproven remedies can be a nuisance for no good reason.

    Now, I did carefully drink my lukewarm coffee, because it was 9:00 am, and I needed my coffee. It took about 2 hours for the numbing to completely wear off. :)

  8. Reductionist Nurse says:

    One of my rather bright nursing instructors told us during a toxicology lecture that amalgam fillings seep mercury. I attempted to correct her and she evasively replied that she knew a dentist who had to leave practice due to tremors from chronic mercury exposure. Later that week I told my dentist about it and they were furious that pseudoscience myths were still sneaking to academia, to my satisfaction.

    I am a believer in Mark Crislips use of evidence-based ridicule as an effective tool for getting through the thick skulls of true-believers. I present myself as one anecdote to support that method.

    Years ago I used to be a casual reader of Natural News(or as it was previously called, “News Target Network”) as well as Mike Adams. One day, Mike Adams make an unusually absurd assertion. This prompted me to google “Mike Adams Fraud” which led me to Orac’s rundown on Adams and ultimately I ended up here.

    Stopped wasting my money at the natural foods store and have been a hard skeptic ever since.

    PS
    I did hear a good podcast by Brian Dunning on the subject as well:
    “How to Be a Skeptic and Still Have Friends”
    http://skeptoid.com/episodes/4116

  9. Fredeliot2 says:

    The theory of Cognitive Framework seems to fit quit nicely. Basically to get someone to understand your arguments you have to get them to modify their cognitive framework before you present your facts. A science based framework should have a robust set of rules for evaluating facts while a framework based on dogma is very difficult to deal with. Most people are somewhere in between. Getting someone to run their own test is a good example of getting someone to modify their framework.

    I once encountered a nurse who considered herself to be an expert on Therapeutic Touch. Rather than point out the absurdity, I switched the subject to acupuncture and how the interaction between caregiver and patient was the chief factor in the outcome. She was able the understand this and hopefully realized how this applied to TT. There are social situations where you have to do things a tiny step at a time. What is needed is “Modifying Cognitive Frameworks for Dummies”.

  10. CarolM says:

    Not to psychologize but I went around and around about this with a parent many years ago, and I got the distinct impression that it was a reaction to something that seemed out of control, namely aging and weight gain.

    Getting old is scary so you start gobbling pills. Taking the weight off is hard so is there a magic pill I can take? Like that ridiculous Prevention magazine, chock full of things you can put in your mouth to solve all your problems. A very sick and morbidly obese woman at work used to give me her old issues. There was always a thin healthy young woman on the cover.. Every month is was some new reductionist deficiency & cure-all, like Lecithin, Niacinimide or Papaya enzymes. Like today with Vitamin D.

    It’s faith because they don’t know how else to approach their daily lives.

  11. S.C. former shruggie says:

    True believers are a real hassle. I find talking with them is like commenting on Age of Autism – all disconfirmatory posts get deleted.

    I’ve been able to scrub the CAM my family favoured as I grew up out of my head precisely because I regard that kind of willful ignorance as a hallmark of error. I make a point of mentioning my own past experiences with herbal treatments and delusional parasitosis in the hope people will be less defensive, (it’s best to make it clear you laugh with people, not at them,) and I make a point of mentioning that experience says discounting evidence and avoiding questions is something we do when we’re wrong.

    So far, not much to show for it. I’ve found it easier to disabuse people of exaggerations and propaganda of anti-seal-hunt activists than to disabuse them of fraudulent health claims. People aren’t as emotional about baby seals. (Also people care about unemployment and closing of rural sealing towns in Newfoundland.)

  12. icewings27 says:

    I’ve had some success in asking people who make statements about their woo beliefs “why do you believe that?” or “how do you know?”

    If they reply that their “doctor” (usually a naturopath or some such other quack) told them so, or that they read it on some lame website, I suggest that they search Pub Med or Science-Based Medicine for actual evidence.

    Then I tell them how much I have learned from both sources and that they both do a great job of summarizing and/or abstracting complex medical research and studies into layman’s terms.

    I got my niece to quit buying homeopathic medicine and got her to go to a real (medical) doctor. And I got my sister to quit seeing an osteopath who was charging her $300 a session.

  13. Amy says:

    I’m in the boat CarolM was in, and I wish I had the answer, if anyone wants to help! My father who was a completely practical man has turned a bit woo-ish as he ages. maybe taking supplements feels like he has influence or control. so far it’s only been things that probably effect his pocket book more than his health, but I worry where it will lead. And he’s already told me, science won’t convince him so-n-so supplement doesn’t work; what are you suppose to say to that?

  14. vicki says:

    Amy,

    Maybe go at things sideways: “The point of supplements is to give you things that are missing from your diet, and getting them in your food is better for you. Besides, wouldn’t you rather have some blueberries than a pill?” or “I’ve heard that those supplements don’t work by themselves, they’re only a help if you also exercise” and then encourage him to either take up or continue an exercise program.

    That won’t de-woo him, but walking or swimming or lifting weights would be good in their own right.

    I’m just guessing: my mother and her sisters seem to be thoroughly uninterested in or resistant to woo, so I haven’t had to actually use this.

  15. GreenGridGirl says:

    Amy, when my mother-in-law was into herbal supplements we used the issues of purity and lack of regulation of the supplements when discussing why they weren’t the best idea. Ultimately it’s been a few things that have resulted in her backing away from the woo some, but we think pointing out that her worries about safety over many things should also extend to these products (despite them being “natural”) helped some.

  16. Beowulff says:

    Confrontation seldom works: it just makes people angry. It is counterproductive: it only serves to make them invent more rationalizations to defend their beliefs.

    Then again, avoiding confrontation doesn’t really work either. First, avoiding confrontation can make your argument look weaker than the opposing argument. And second, you generally can’t avoid confrontation to begin with, as simply calmly stating the accurate relevant information is already often seen as being confrontational.

  17. pmoran says:

    I like the idea of “building bridges” because it implies some preliminary analysis of the terrain — on both sides of the gap.

    Beyond that I have little. I see a daunting collection of different challenges, depending upon who you are talking to and what you hope to achieve.

  18. Anthro says:

    “you generally can’t avoid confrontation to begin with, as simply calmly stating the accurate relevant information is already often seen as being confrontational.”

    This is the problem I have had which has led to the loss of friends as mentioned in my previous post. If I recommend PubMed, etc., I only get, “I’m not a science person–I go by experience”. What do you say to a statement like that?

    I have considered that I am better off without these science illiterates as friends, but over time, there have been quite a few losses. I decided, finally, that I simply travel in the wrong circles, so I recently joined a skeptics group to try to change the type of people I interact with. I think that might be a better approach for me.

  19. nybgrus says:

    Anthro – your name makes me snicker a little at myself. I have an undergraduate degree in athroplogy, and took many medical anthropology classes. Throughout my studies I was vehemently told that “western biomedicine” reductiontionists were evil and constantly trying to push gentle mild mannered “eastern medicine” people out purely for selfish business and ideological reasons. I was taught that ayurveda, vietnamese hot/cold, chinese tradition, etc were all equally valid ways of healing. I bought it wholesale – after all, I was being taught these things in a well respected university while concurrently taking rigorous biological sciences courses. My university had FIVE Nobel Laureates in the sciences on staff – hell, I did my studies in buildings named after them. Even after I graduated I still espoused these beliefs – in fact, I advocated the integration of medicine long before I had ever heard that term or before it became as fashionable as it is today. I even have a sneaking suspicion that my difficulties getting into med school were because I wrote about such integration and woo-woo garbage in my personal statements. Hell, I even believed that homeopathy could have something to it and argued with a UCLA professor about it over beers.

    What changed for me? I continued to pursue science and actually got into medical school and started learning mechanisms. I discovered that my undergrad science was merely a hodge-podge of memorization of a plethora of facts (which, don’t get me wrong, serves me extremely well at the moment) but without a deep and genuine understanding and appreciation of what the scientific method was or what it meant to be a scientist. Through meeting the right friends, reading this blog and others, my eyes were opened – wide. I am truly the epitome of the fact that you can learn science facts without actually learning what science truly is. I can fully appreciate how I (and anyone) could make it all the way through 4 years of med school and be prone to such wooish beliefs.

    Now, I adopt a hard stance. In anything I write, I make no apologies or offer place of comfort for magical thinking. In my personal and professional life I temper that and tailor my messages to the audience I am currently addressing. I speak up (probably a bit too much) and make a point whenever I can. This sometimes leads to people thinking me a bit brusque, a bit of a know-it-all, and I am certain some people disregard me for it. However, what I find is that I get a number of fence-sitters come my way. I’ve been approached by a few of my classmates asking me why acupuncture doesn’t work. And we sit and chat about it. I have opened their eyes to the fact that this magical thinking and woo is actually happening and it is important to give it no quarter. They usually are not as engaged and passionate as I am but at least now I know they will keep “spreading the word” when confronted about such things. And I know they will have a more critical eye in the future.

    As for my successes:

    One of my classmates began debating anti-vaccine loons. She proudly informed of this, saying I was her inspiration to become more active and interested in such things. When she came to me saying she felt it was pointless – that she would never convince these idiots and was feeling like giving up – I told her why she shouldn’t. Namely, that the goal with debating these people is not to convince them. You never will, so don’t expect it. Your goals are twofold. 1) Hone your own rhetorical skills and build your scientific knowledge relevant to your debate. This will let you become better and faster at it and will also help your medical studies since the science is relevant to what we are studying. 2) Be that bastion of critical and skeptical thought. Give other fence sitters a chance to see that there is a lot of thoughtful critiques of such magical thinking. The worst thing for a fence sitter to see is everyone agreeing with the magical thinking they are prone to themselves. It is for this latter reason that I do not accomodate online – leaving a middle ground for fence sitters to flounder in is completely worthless. You wont convince the die hards, you’re doing nothing either way for the skeptics, and those in the middle will contentedly grab for the gray area you leave them.

    My biggest personal success however was in a debate with creationist. It took about 7 months of back and forth emails. I would write an average of about 25-30 pages per month in rebuttal and so would he. I learned more about evolutionary biology in those 7 months than I did in most of my undergrad classes combined. And at the very end, I received an email saying that he had been forced to reconsider his stance on creationism because I had so thoroughly, thoughfully, and consistently given him detailed explanations of the evidence for evolution. I had cracked his armor. He said he would have to re-evaluate his views from within the construct of his faith, but for me that is a massive victory. If he were to continue in this vein of critical thought and realize that if he could be lied to about creationism then many other things he believed could be lies… well, I smiled that day and moved on. I no longer debate creationists. Because for that one I cracked, I had dozens of others who didn’t budge. I had learned what I needed and could move on, one success under my belt.

    All of this though, is from persistent, conscientious, thoughful rhetoric – with absolutely no accomodation.

  20. About 75% of the feedback I get for my blog about alternative veterinary medicine is of the hate mail variety. But the remainder is mosty people who appreciate the effort I make to spread information and a science-based perspective. And what most seem to really appreciate is finding someone who shares their skeptical perspective.

    An old psychology study put a subject in a room full of investigators posing as fellow subjects and asked everybody to answer simple, obvious questions. When all the fake subjects picked the wrong answer deliberately, it was the rare true subject brave enough to buck the crowd and give the right answer. But when even one of the plants gave an answer different from the crowd, even if it wasn’t the right answer, almost all the subjects were able to say what they really thought.

    I see myself and blogs like SBM not only as sources of information but as a source of permission for those who are doubtful about unscientific medical approaches to say so openly. Even if we change few minds among the commited, we perform a service for the majority without a firm position.

  21. penguinsix says:

    I often wonder if terms like “Skeptic” or even using the term “Quack” are harming more than helping. They are charged words that elicit a charged response. Calling someone a “Quack” for example, while totally appropriate and accurate in many cases, is also presenting a final judgement (i.e. your final opinion of this person) rather than laying out the convincing and overwhelming evidence that made you come to this conclusion. I sometimes feel if we lay out the facts people will follow them to come to the same conclusion. We don’t have to push them down the way saying “your final goal is to find this person a quack as I have done” but “take a look yourself and see what you think.”

    In my own conversations I’ve found an overwhelming dose of evidence and appeals to “think rationally and logically” have done wonders. I’ve asked people “do the math”. Citing the statistics and saying “do this and you have x% chance and do that and you have a y% chance”. When I run into “my own experiments with my children tell me this” I often ask “which child did you sacrifice to the control group?” and then explain the need for such a group (and the need for much larger sample sizes). Trying to instruct somewhat on the process rather than the results has worked in some cases.

    Tangentially related, my father was a professor of science education, teaching science teachers. One of the issues that constantly came up was “how will you deal with evolution vs. creationism”. One of his take homework assignments was to watch Spencer Tracy and ‘Inherit the Wind’ but he later happened across a new assignment which was more instructive. His students had to watch one hour of the tv show COPS and then come up with a plan to talk to the participants in that show (i.e. the wife beater, the screaming neighbors, the fighting drunks) about science and how their children were doing in school. Quite a few interesting answers came from that simple assignment.

  22. kulkarniravi says:

    Harriet,

    You start with a very admirable title, “How to Build a Bridge” but most of your article is about convincing others as to how wrong they are! I don’t think you will get very far with that attitude, even if traditional medicine is completely right about everything – which they aren’t. Perhaps you should begin by asking them why they traditional modern medicine instead. You may get some interesting answers.

    I don’t know where to begin. I have a vague feeling we have had this conversation before, but let me try again. Traditional medicine may be science based, but it is an incomplete science. You can use logic to prove anything, but if you start with bad assumptions, you will end up with seemingly scientific but invalid conclusions. Let me make just two observations –

    Doctors do not study diets and nutrition in any detail. Given that how do the doctors know about the efficacy of the medicines they prescribe for an individual patient. Clinical trials clearly can’t take into account wide variety of diets and even if they do they can not possibly match the real-world scenarios. Of course the typical retort is nutrition and diets do not matter so much.

    Humans and bacteria have a wonderful symbiotic relationship. Is this factor taken into account while diagnosing illness? I doubt it, as it is only now becoming clear that people can be distinguished based on the dominant strains of bacteria they carry. Over prescription of antibiotics have killed off bacteria in the gut, and how does that affect a person’s health. Doctors really do start early – as early as infancy – to start prescribing antibiotics for viral colds.

    The bridge can only be built if common man’s illnesses can be addressed successfully. Tradition medicine does only a patchy job when it comes to most chronic illnesses. That’s why a lot of people turn to other sources for relief.

  23. kulkarniravi says:

    Sorry about the first paragraph, I should do a better job of editing. It should read -

    You start with a very admirable title, “How to Build a Bridge” but most of your article is about convincing others as to how wrong they are! I don’t think you will get very far with that attitude, even if traditional medicine were completely right about everything – which they aren’t. Perhaps you should begin by asking them why they disbelieve traditional modern medicine instead. You may get some interesting answers.

  24. kulkarniravi says:

    nybgrus,

    I have always wondered why do most doctors appear to have a very rigid attitude when it comes to their profession. After reading your comment above my theory about medical education is becoming more concrete.

    The establishment encourages this kind of thinking. In fact they completely discourage any independent thinking. That’s the reason for total prohibition on any common sense approach, everything has to be studied in a clinical setup, though it doesn’t begin to approach real life.

    Doctors seem have this attitude that what they know and practice is perfect. I am not saying that it is a pretense- doctors do really believe it. Medical science is anything but an exact science. There are so many unknowns. Given all the unknowns, no matter how much science you use to support your methods, it will still remain at best a guess work.

    What’s worse, lot of laypeople seem to believe that doctors know everything. This is a dangerous belief as it prevents them from getting a second opinion, doing their own research or pursuing other options. I have seen a lot of people doing this as well.

  25. hyperlalia says:

    “Doctors do not study diets and nutrition in any detail.”

    As a second year medical student currently taking a course in nutrition, I must politely disagree.

    That said, in light of the significant illness related to caloric over-nutrition it might be more prudent if medical school curricula devoted more time to the field of nutrition and less time requiring me to memorize pedantic details regarding how to differentiate between exceedingly rare types of kidney diseases based on images of kidney cells taken with an Electron Microscope.

    Does modern medical training do a perfect job of teaching the important details of nutrition in health and disease? I don’t know, I’m not even halfway done yet- but my guess would be no. Does medical training “not study diets and nutrition in any detail”? Well my experience in medical school courses so far in Biochemistry, Histology, Physiology, Parasitology, Neuroscience, Genetics, Microbiology, Pathology and my current work in a Nutrition course do not support that statement.

    Is medical research into nutrition and related topics woefully under funded? Likely. But until nutrition becomes as profitable a field as pharmacology I don’t see that trend changing in any substantial way.

  26. Harriet Hall says:

    @ kulkarniravi,

    I was writing about bridges to correct misinformation, not to impose opinions on others. If you can show that we are misinformed, we would be happy to look at your evidence; but so far you have only given us generalities, platitudes, and questionable claims.

    Of course science is incomplete. We need to do more and better science, not replace it with unscientific mythology or guesswork. If clinical trials can’t take diet into account, what can? How could we go about predicting the efficacy of a medicine for an individual patient? How exactly would you suggest we take symbiosis with bacteria into account when diagnosing illness?

    We are confident that science, imperfect as it is, is the best tool we have for understanding reality. Do you disagree? Do you think you have a better method?

    By the way, modern scientific medicine does not use antibiotics for viral URIs. Overprescription is an error of individual practitioners based on false beliefs of both doctors and patients: just the kind of misinformation we need bridges for.

  27. kulkarniravi says:

    Harriet,

    “By the way, modern scientific medicine does not use antibiotics for viral URIs. ”

    But the reality is something quite different. Here is a Canadian study in from 1998:

    http://cid.oxfordjournals.org/content/29/1/155.full.pdf

    I don’t think it has changed by much and that it is any different in the US either.

    Clinical trials are flawed because they do not take diet into account. Just to give you an example, how could they possibly emulate the diet of an Indian peasant who does 10 hours of hard work and then eats a vegetarian diet, that is filled with simple carbohydrates. Perhaps they do and I could be completely wrong, but somehow I doubt it.

    1. Harriet Hall says:

      @kulkarniravi,

      You failed to understand my distinction between what science recommends and what misguided individual practitioners do. The link you provided supports my point, not yours. It is an article in a medical journal that directly addresses the problem of over-prescribing and chastises doctors for not following the principles of scientific medicine.

      Why do you think a clinical trial should “emulate the diet of an Indian peasant who does 10 hours of hard work and then eats a vegetarian diet, that is filled with simple carbohydrates.”? Should it also emulate the diet of an Eskimo who works in sub-zero temperatures and subsists on raw meat and blubber?

  28. pmoran says:

    Clinical trials are flawed because they do not take diet into account.

    A clinical trial could easily be designed to “take diet into account”. There would merely have to be grounds for considering diet relevant to the outcomes being sought.

    So you do need to clarify what you have in mind.

  29. nybgrus says:

    Kulkarniravi:

    You have once again completely missed the point. In my little tale of my personal saga, I was demonstrating that it was the anthropology professors who pigeonholed me and did not allow me to think for myself. It was the people telling me how incredibly important diet was, and how scientists and doctors thought they knew it all that were in fact stifling my independent thought. It was my anthropology professors that yelled at me and said that western medicine was evil – and when I tried to speak up and offer independent thought they simply shut me down. I’ve never seen a professor in such a huff as these. When it came time to review exams, it was these professors that would not accept any answer that did not agree with their ideology, no matter how well reasoned. Believe me, I do not exaggerate.

    However in my science degree everything was quite different. Occasionally I had the professor who would quite sternly tell me (or anyone) that they were wrong about an answer. Occasionally it was without further follow up. Sometimes they were just jerks, sometimes the student was being a jerk and the answer was simply plainly wrong. However, the vast majority of the time I found my science professors much too accomodating. They would take extra time to explain the mechanism and try and show the student (including me) why we were wrong. Sometimes I was baffled at how much leeway they gave to students in trying to spin answers for partial credit – they were simply much too nice to them, in my opinion. And ultimately if you did not agree you could very easily memorize and regurgitate the answers on an exam and move on. They simply figured that either the student would drop out of sciences and not care or they would (like me) finally figure it out.

    The anthro professors would actually hound you and tell you how wrong you were. They would actively chase you down after class to do so.

    Please, read those paragraphs carefully and notice that the science department was actually humble and accomodating and fostered independent thought, critical thinking, and understanding. It was the anthro department, especially medical anthropology, that were completely unrelenting and downright angry and righteous in their ideology.

    So please, do not twist my words to conform to some preconceived conclusion about doctors and medicine.

    On that note, if there is any place I have ever been that attempts to actively foster independent thinking and application of knowledge it is medical school. You know what I get asked more than anything else, every single freaking day? “Explain to me why you would do that.” Every day we are reinforced with the idea of thinking through a problem – if a patient presents with X what would you do? And when we answer, it is almost always followed up with, “Why would you do that?” If we immediately say something like “Do an expensive test” or “Give them a drug” we would be chastised and say “Lifestyle, diet, and exercise first then if all else fails, drugs.” Or, “why would you order that test when a good history and physical will give you the same information?” Or, “How would that test change your management? What would it actually help you do for the patient?” And here is the kicker, kulkarinavi, if I have an explanation and can cite a new study that shows my reasoning to be sound… I get listened to! And a rational, critical, thoughtful discussion ensues and ultimately we come to an understanding and, yes, there are times (not often and only on minor points) that a doctor learns something from me, a student.

    So where on earth could you possibly get the notion that medical school does not engender independent thought and critical thinking?

    However, I can, if I choose, completely avoid such confrontation. I can memorize what I need to pass my exams, do the minumum requirements to have the school sign off on my degree, and weasel away without ever fully appreciating the scientific underpinnings of medicine. But that is the point – I would have to try and do that, or be that way inherently. And that is why I say that just because you have an MD doesn’t always equate to being a scientific or critical thinker. You must decide to do that yourself. Otherwise you end up like Dr. Oz.

    In regards to your continued claims about nutrition please, stop making uninformed claims. Do you have any clue what the actual medical school curriculum is like? Can you name the classes we cover and what the actual syllabus says? Have you ever audited a class? Can you cite some references? Every time you have made such claims you have been refuted stating that we do learn nutrition – but that your notions of what “learning nutrition” means are erroneous. Perhaps you should listen to the audio lectures by Edward Goljan to prep students for the board exams. I was listening just yesterday and heard him screaming in my ear about how the exam is “all about prevention people! You need to know your nutrition! You need to look for the EASIEST, most available, solution BEFORE medications! The boards will ask you how to manage a patient with hypercholesterolemia and obesity and if you answer “statin” you are WRONG! Diet! Prevention!” If you don’t believe me – get the lectures and LISTEN. But please, stop spouting random notions about how you THINK doctors are educated.

    Yes, the system is not perfect. Yes, students can become doctors without really learning what they need to and how. Yes, nutrition could be taught better – but so can just about everything. And yes, I agree that in general more nutrition research would be a good thing. But please, stop your ignorant claims.

    And lastly, before I turn this response into its own seperate blog:

    Medical science is anything but an exact science. There are so many unknowns. Given all the unknowns, no matter how much science you use to support your methods, it will still remain at best a guess work.

    Of course it is not an exact science. You are fighting a straw man here. Why do you think the blog is called science based medicine?? Because we BASE our medicine in science. So yes, we will always have to use clinical judgement and draw upon a vast amount of knowledge to make that judgement as good as possible. Why do you think we do four years of undergrad, 4 of medical school, and then 3-6+ years of residency? That is 11+ years of INTENSE study and hands on experience. And you have the arrogance to make the asinine claims you do. Why do you think “Doctors seem have this attitude that what they know and practice is perfect?” Because we know so much more than you about the relevant science and medicine. But we never are under the assumption our practice is perfect. That is what you think, not us. And I can assure you, it is NOT what we are taught. But no matter how much is yet to be known, it is NEVER guesswork. What YOU do is guesswork. What doctors do is apply that vast body of knowledge to come up with good clinical decisions. The fact that they can sometimes be wrong and mistakes can be made is simply the nature of humanity and how much we do now – NOT an indictment of the system.

    And lastly, I will say this AGAIN: A second opinion implies that the opinion should also be VALID. You wouldn’t ask your plumber for a second opinion on your prostate cancer. You wouldn’t ask your tax attorney for a second opinion on your lung cancer. So when you say “What’s worse, lot of laypeople seem to believe that doctors know everything. This is a dangerous belief as it prevents them from getting a second opinion, doing their own research or pursuing other options.” that is entirely disingenuous and misleading. Because laypeople should know that doctors are the ones to seek a first AND second opinion from. Not chiropractors, naturopaths, homeopaths, or Chinese traditional medical practitioners. And nobody is preventing a patient from doing their own research – in fact we encourage it and are taught from day one in med school to form a partnership with patients where they can inform us about their desires, values, and needs and we can find the best EVIDENCE BASED ways to meet those needs.

    When the science has no answer (since, as you correctly point out the science isn’t perfect and complete) the answer is NOT to turn to woo garbage and “just know” that CoQ10 cured your blah blah blah.

  30. BillyJoe says:

    Harriet: “When I was in the dentist’s office earlier this week he asked me what I thought about detoxification.”

    Michele: “I had an experience Monday…I had to have my mouth numbed at the dentist for a filling replacement.”

    That makes three!

    I attended a dentist last Saturday for the first time in longer than I can remember. It was an emergency. I’d broken off about three quarters of a front tooth. They gave me to the “dental student” – a very young chinese girl, not yet experienced enough to fake looking confident. The result however was amazing! Indistinguishabe from the original. I’m seeing her again in two weeks to start a dental restoration that will see her into her first beachfront home!

    The connection to this thread:
    I’m going to ask her about mercury.

  31. lamamaloca says:

    nybgrus — awesome comment. Very thorough. :)

  32. icewings27 says:

    nybgrus – Ditto what lamamaloca said. Excellent rebuttal!

    Do you have a blog of your own? I will read it, if you do. If you don’t, you should start one.

  33. Scott says:

    I suspect that kulkarniravi will respond to:

    Should it also emulate the diet of an Eskimo who works in sub-zero temperatures and subsists on raw meat and blubber?

    with a “yes,” and then some claim that unless it does both then it’s meaningless, and that trials are therefore “flawed.”

    A better analogy would be to ask whether a clinical trial should control for the color socks the subjects wear. Both are observable differences between the subjects, both could in principle be controlled for, but neither is in general relevant to the results.

  34. Zetetic says:

    nybgruson:

    Your responses to Kulkarniravi are elequent and right on! There are mountains of erroneous urban legends and memes within the alt med realm about what they THINK is taught in medical schools and public health graduate programs.

  35. JPZ says:

    @Harriet

    Thank you for this insightful post! Another aspect of building bridges is that engaging a true believer may not change their mind, but it may build many bridges to your audience. Also, I feel respectful engagement is essential to building bridges with the not-yet-true-believer. If we have the humility to say we may not know all there is to know about a subject and genuinely listen to the “why” of a belief, we may be able to more productively build bridges. A person who tried a CAM treatment once and liked it is very different from someone who realizes the limitations of a CAM treatment but derives psychological comfort from its use. In the later case, you need to make sure that disproving the CAM treatment doesn’t do more harm than good.

    I think we all know people in SBM and CAM that could benefit from more active listening and (as you put it so well in your post) more building bridges.

    Also thank you for quoting the comedian Dara O’Briain about science knowing it doesn’t know everything – he’s done some of the best science-based humor I have heard (even if it was just a few minutes of one show – http://nutrition-industry.blogspot.com/2011/03/science-doesnt-know-everything.html ).

  36. JPZ says:

    @nybgrus

    I just read your long post, and you make many good points. The American Society for Nutrition is working with medical schools to develop science-based and comprehensive nutrition curricula for health care providers. So, the process of improving clinical nutrition education is ongoing.

    I would ask a slightly different question than the one you answered: Does medical school education predispose doctors to dismiss health-related information that does not come from other physicians directly or indirectly (e.g. continuing ed, journal articles, drug companies, etc.)? There are numerous exceptions of course, but for most doctors? Getting some physicians to accept the insights of an RD or RN can be a challenge.

    If yes (and I am not automatically assuming it is), do you see how this dismissiveness could be a barrier for building bridges and having meaningful discussions about what works and what doesn’t in CAM? (I added this last paragraph because the previous one might not look relevant without showing where I was going with the question)

  37. pmoran says:

    K, many of your perceptions have some truth, e.g. –

    For most of the last century medical education WAS very authoritarian.

    Skeptics don’t usually turn their blowtorch minds back onto the mainstream so as to fully appreciate the limitations that lead many to try out CAM.

    Clinical trials do have limitations, although it is not clear that they are quite the ones you think. (They are NOT the only, or even an important route for the expansion of medical knowledge, they merely make it more certain).

    These factors may help justify the existence of a kind of maverick medicine where people form various walks of life try out this theory and that remedy in their garages. Is that what you want to defend?

    I don’t think anyone can argue with that, and it might even occasionally produce the goods.

    What we can point out is that such activity does not have a very good track record of success. The hit/miss ratio in practice, even for august Nobel Prize winners such as Linus Pauling, is so unfavorable that we skeptics might be forgiven for being a bit — well, skeptical.

    I nevertheless think that people can derive useful non-specific beneifts from CAM-based medical activity. They just need to understand that it will not cure established cancer or other major illnesses.

  38. kulkarniravi says:

    Harriet,

    You missed my point too. What matters is what is in practice and what are the end results, not some abstract but good principles. One could argue about what leads these practitioners to do these things, but in the end, as a consumer, I need to depend upon my own resources. It is not good enough to listen to my doctor.

    As regards to the clinical trials, my point is that clinical trials could not possibly emulate the diets and lifestyles of every ethnic group and racial group in the world. That’s the intrinsic weakness of the clinical trials. And yet, medical profession tends to use the resultant drugs in a one-size-fits-all fashion. Oh I am sure, you do some due diligence, such as whether there are any known factors that could affect the efficacy, other medicines being taken by the patient etc, but in general most drugs are probably not tested on an Indian peasant or an Eskimo. Thank you for clarifying this matter!

  39. BillyJoe “The connection to this thread:
    I’m going to ask her about mercury.”

    I once asked my dentist (not the same one as above, but his dad) about fluoride. I was basically trying to discern the appropriate fluoride level in toothpaste for toddlers. But, I got a very interesting history of the discovery and use of fluoride as well.

    As an aside, I chipped 3/4 of both of my front teeth off in a rollerskating accident as a child. Make sure to ask if your repair will need any extra care, mine are often chipping off, but I think the modern ones are much more durable.

  40. For many years now I have been writing about rational self-help options for common painful problems (see SaveYourself.ca, start with the reading guide for skeptics) and I am happy to say that I get a great deal of heartening email of the “thanks for bringing me around” variety. This has also improved: I used to get a lot more hate mail than I do now, so apparently I’m doing something more right than I used to. Here are my impressions of what strategies build bridges and trust with people who don’t yet agree with you:

    • Humour, humour, and also humour. Funny, that.
    • Candid self-deprecation is very disarming. I’m terrible at it, but I do my best.
    • In particular, go out of your way to show that you know you can be wrong.
    • Rigorous, thorough, substantive referencing!
    • Story-telling and anecdotes that challenge the hype. Antimonials rock.
    • Always, always get agreement on easy, smaller points first. Once someone is nodding, they tend to keep nodding.
    • Make it about the money. Time and again it’s the consumer advocacy angle that turns on the light bulb. No one wants to be perceived as a sucker.
  41. JPZ says:

    @Paul Ingraham

    Excellent insights. Thank you!

  42. Paul Ingraham – All excellent ideas, I think I will get them tatooed on my inner arm for my next social encounter.

    But this one made me chuckle out loud.

    * “Candid self-deprecation is very disarming. I’m terrible at it, but I do my best.”

  43. JPZ says:

    @micheleinmichigan

    Warning to CAM enthusiasts, if someone rolls up their right sleeve at the start of a conversation at a cocktail party – RUN!

    LOL

    I am putting the whole list on my hard drive (I don’t have a thing for tatoos).

  44. nybgrus says:

    lamamaloca, icewings27, zetetic, JPZ: You are much too kind, but thank you. I do have a blog, but it is a food blog of my (and my girlfriend’s) recipes so I doubt that would be terribly interesting or relevant.

    JPZ: “Does medical school education predispose doctors to dismiss health-related information that does not come from other physicians directly or indirectly (e.g. continuing ed, journal articles, drug companies, etc.)?”

    I don’t know if I can really accurately comment on it since I think my experience is rather different than my “average” classmates if you will. But I would venture to say that no, in fact if anything most students are much too willing to accept health-related information from sources that are less than credible. We have lectures on integrative medicine that overstep their bounds in advocacy for dubious treatment modalities, planting (IMO) a seed of credulity. Additionally we have symposia and other lectures on CAM not from the IM guy that discuss the concept of what CAM means in a patient centered way. In other words the notions of listening to patients themselves, as well as being able to take in, assimilate, understand, and either refute or adopt information from such avenues is something directly taught to the student body.

    How effectively that is done is another topic. I personally think that the credulity needs to be dialed back a bit, but overall I reckon it is doing a good job. As has been pointed out this shift from authoritarian and paternalistic medicine to a patient centered one is relatively new. There still exists an “old guard” that have not adopted the bedside manner and skills in this department. However the change is certainly palpable and, ignoring for the inevitable touch of “new-resident-arrogance” , I would be willing to wager that most of the “newer” physicians would be able to do exactly what it is we are talking about. And I think that it is being done the vast majority of the time.

    But I can most certainly appreciate how those few that are from “the old days” or who just simply don’t get it or are obtuse jerks could certainly turn people away and that attitude would be a very significant barrier for bridge building.

    kulkarniravi: I hate to say this but you have missed the point yet again (and once again make assumptions about how we are taught).

    What matters is what is in practice and what are the end results, not some abstract but good principles

    Indeed – but throwing out the system as you consistently advocate is patently the wrong approach. You cite the failures of modern medicine and then try and throw the baby out with the bathwater. You assume the system is fundamentally broken – our illustrations here show it is not. If the teaching is there, and the professional ethos is there, but it is somehow not being translated into actual practice then it is the step between that needs to be addressed. And that is exactly what this blog does and what people like myself advocate. We strive to fix that disconnect – to ensure that all doctors practice evidence based medicine (in other words, to ensure they do NOT give antibiotics for viral infections) and that they treat their patients as human beings, not diagnoses on legs. You malign the whole system and try and claim there is some other equally valid way of doing it. Yet you have no citations or evidence for it – you just want to do away with medicine and do whatever feels good willy nilly. That is a terrible approach.

    Furthermore:

    As regards to the clinical trials, my point is that clinical trials could not possibly emulate the diets and lifestyles of every ethnic group and racial group in the world. That’s the intrinsic weakness of the clinical trials.

    Do you really think you have dropped some bombshell of knowledge on our collective heads? Do you honestly think for one second that I, for example, had never once thought of that? Do you really think that in medical school we are taught how to read and understand a study but somehow are oblivious to the notion that they are limited in their scope?

    I will have you know that we are taught, in painstaking detail how to not only read, but understand, validate, use, and apply study and clinical trial data. I am blown away that you would assume as fact that we are simply told “here is a paper – if it says drug X is good then use it willy nilly!” Please! We learn about such things as:

    Sensitivity, specificity, internal validity, external validity, study design (and the imitations thereof), ethics of clinical trials, power of a study, importance of sample size, drop out/response rate, blinding, adequate controls, and demographic of the population studied, just to name a few off the top of my head.

    And most importantly it is hammered into us that our patient is likely NOT exactly like the population studied in the clinical trial for a NUMBER of reasons and to take that into account when thinking about the implications in regards to our specific patients. Yes, incredible as it seems, you are not the first person to magically figure out that studies have their limitations and the need to take that into account.

    So when I am treating “an Indian peasant or an Eskimo” I will take that into account. But when I am treating a white, middle aged male, who otherwise meets the demographic of the study population I can be more certain the results will apply to my patient.

    I suggest you take a look at the Fresno EBM assessment with marking criteria to have a quick look at how we are actually taught about these things.

    Once again, I implore you to stop making erroneous assumptions about something you clearly have no idea about and have not even taken the time to research.

  45. Mark Crislip says:

    Those are indeed excellent. Esp since antimonials are an old treatment for syphilis and a current treatment of leshmaniasis.

  46. Chris says:

    nybgrus:

    You are much too kind, but thank you. I do have a blog, but it is a food blog of my (and my girlfriend’s) recipes so I doubt that would be terribly interesting or relevant.

    Then you should perhaps do more guest articles on this blog, in what time you have left over from medical studies. There should be a link at the right for articles written by medical students and other guests.

    (Plus, I glanced at the sparring between you and Dr. Moran… might I suggest that since you two are presently on the same continent that you have a friendly debate in person? Perhaps at the next TAM Australia.)

  47. Harriet Hall says:

    @kulkarniravi,

    Please answer my questions:

    ” If clinical trials can’t take diet into account, what can? How could we go about predicting the efficacy of a medicine for an individual patient? How exactly would you suggest we take symbiosis with bacteria into account when diagnosing illness?
    We are confident that science, imperfect as it is, is the best tool we have for understanding reality. Do you disagree? Do you think you have a better method?”

  48. Harriet Hall says:

    @kulkarniravi,

    “What matters is what is in practice and what are the end results, not some abstract but good principles. One could argue about what leads these practitioners to do these things, but in the end, as a consumer, I need to depend upon my own resources. It is not good enough to listen to my doctor.”

    We can agree that the end results are what is important to the patient, and that the implementation of scientific medicine needs improving. I can understand that it isn’t good enough to listen to your doctor if your doctor isn’t practicing good scientific medicine. But what are your criteria for deciding if he is or not? And how do you know your own resources are reliable enough to depend on?

  49. nybgrus says:

    @chris: Once again, kindness I do not deserve. Although I would like to write another piece I have been rather busy over these last few weeks and whenever I find myself having some time I find that a movie with a glass of wine cozied up with my girlfriend sounds better…. I honestly can’t fathom how Dr. Gorski manages to be so prolific.

    Besides, I am still very much learning and it is through these commentaries back and forth that I learn so much.

    As for Dr. Moran – I honestly have utmost respect for him. He manages to keep much cooler than I do and even though I disagree with what he says a lot of the time, I don’t feel like he is being ideologically obtuse. I will only be in this country for another 6 months, however, since my program has me completing my training in 3rd and 4th year in the US (I am an American). Since TAM Australia is at the end of November I will miss it by a couple of weeks. However, if Dr. Moran is in the Brizzy area I’d certainly be keen to have a gentlemanly chat over a few beers if he is.

  50. kulkarniravi says:

    Nybgrus,

    I chose to reply last to your posts because I decided to go back and reread everything you have said in this blog. Let me just say this: your answers and explanations are very articulate and thought provoking. While I don’t agree with everything you say, I must say your patients are very lucky to have you as their doctor. I rarely meet such doctors personally or professionally such as yourself and if there is a large population that seeks alternative treatments, because there are just not enough of you out there.

    Having completed the sucking up, let me now see about your points. I have asked on these forums the question, how much of nutrition do the doctors study. I also did a google search. Here is a very old article from NYTimes:

    http://www.nytimes.com/1993/02/10/health/doctors-get-poor-marks-in-nutrition.html

    Unless something has changed in the interim, I would say the doctors’ knowledge of nutrition is wholly inadequate given the profession they are in. Add to these factors, a somewhat dismissive attitude people on this forum have taken towards nutrition, I concluded that perhaps nutrition was not studied in much detail. Again, if you could enumerate the courses you took, or a regular medical student is required to take, I will consider myself educated on the topic.

    I have respect for doctors as professionals. I know a lot of hard work one has to put in, in order to get the degree alone. I have respect for the modern medicine for all the work done under its auspices, vaccines, diagnostic methods, emergency care. If there is one single factor that has increased the lifespans across the world, I would give vaccines that honor. If a lot of victims of accidents and wars survive today, I would give emergency care due credit. If a lot of people don’t die of infectious diseases, I would say it is because of antibiotics. I am aware of the accomplishments and by no means I am proposing that we throw out all these achievements. So perhaps you are creating your own strawman here.

    You and others have listed the limitations of modern medicine as well. I certainly don’t need to educate you or anyone else on this forum. What I do want to know is, do all the doctors educate their patients of the limitations of modern medicine. Do they counsel them to do their own research beyond the advice they themselves have given, given all these limitations. Given the gap between the ideal doctor, which you and others on this site project, and the real one which I have to encounter, do you think it is a good idea for patients to do their own research whether it comes to understanding the preventive care or palliative care. Given the lack of adequate nutritional awareness among average doctors, do you think it is a good idea for the lay people to go ahead and pay more attention to their diets and nutritional anyway?

    Recent studies have shown that many herbs do in fact have desirable medicinal effects. For example, turmeric, garlic, peppers, coffee and so and so forth. I don’t see the same enthusiasm among the FDA and doctors to push these health foods as they do for FDA approved, pharma developed drugs. Given this, would you agree that lay people study what’s out there and at least partially try to address many common ailments through these more natural means. That’s not throwing the baby out with the bathwater.

  51. kulkarniravi says:

    Let me also thank everyone on this forum who have taken the time to respond to my inarticulate and perhaps uneducated comments. This is what is building the bridges is all about. I have certainly learnt many things here – it doesn’t change my mind much about diet and supplements – but I do have a little better understanding of what an ideal doctor should be. I hope I will be able to find one such doctor.

  52. kulkarniravi says:

    Harriet,

    “We are confident that science, imperfect as it is, is the best tool we have for understanding reality. Do you disagree? Do you think you have a better method?””

    Currently science is the best method we have – no question about it. Ancient Indians used other methods – perhaps spiritual – it is now lost. They developed many fields of knowledge then by other means. Perhaps that will rise one day again, but for now we only have science.

    For the clinical studies perhaps the researchers are not asking the right questions. Perhaps they use a very narrow criterion for success. Perhaps they do not take the whole organism into consideration, and perhaps they can’t. I have already listed diet, race, culture, and bacterial symbiosis as some of the factors that can’t be completely taken into account while conducting clinical studies. I have also listed the fact that these studies do not go across generations. Does it make an effective clinical study impossible? Perhaps, but health is not an easy subject. Perhaps it will take us several centuries to get a good handle on it. Just because it is difficult to do an ideal clinical study, doesn’t mean we keep using the failed methods again and again. It is like a man searching for a lost ring under the street lamp, but not in the dark corner where he actually lost it, just because there is no light in the corner.

  53. kulkarniravi says:

    Harriet,

    I use a simple criterion – does the doctor do a good job of listening and does the doctor explain why a certain course of action is being prescribed. I am still relatively young, so I also look for prevention advice. If the doctor is impatient or not willing advice, I know I should look elsewhere.

    There are at least some respectable websites – webmd, mayo clinic, fda website are typically good for researching on symptoms and remedies. There are some websites that talk about traditional herbs and supplements which I have found to be effective.

    One personal anecdote. Last year I had a tooth pulled. The orthodontist wrote a prescription for codeine. I decided to just go for otc tylenol and I was fine. Was that a good doctor?

  54. Chris says:

    nybgrus, I assumed you would be quite busy. But if the chance arises, you should think about writing other articles. Perhaps in the next six months the Australian Skeptics will find a venue for you and Dr. Moran (I remember him from my time on Usenet!). Best wishes for the next few months!

  55. Harriet Hall says:

    @kulkarniravi,

    You say you value science, but you also mention ancient wisdom and other ways of knowing (spiritual?) You have a vague concept of somehow taking the whole organism into consideration without any clear idea of what that means or how it could be accomplished. It seems to me you are not thinking clearly, and that rather than truly appreciating the scientific method, you have accepted a belief system that allows you to believe certain things without evidence. Then you say you have found traditional herbs and supplements to be effective. How did you determine their effectiveness?

    Was the codeine prescriber a good doctor? Yes. He anticipated that you would have pain and he prescribed something effective. Could he have been a better doctor by understanding your feelings about pain meds and asking you first if you wanted a prescription? Yes, he would have been a better doctor for you; but that same approach might have made him a worse doctor for another patient. Did you need the tylenol? Would he have been a better doctor if he suggested that you tolerate the pain without any medication, thereby avoiding any possibility of side effects? Is there any way he could have known ahead of time how much pain you would have, how you would react to it, and what decisions you would make? I doubt it.

    When I had a breast biopsy, I had a good doctor. He gave me a narcotic pain prescription. I filled the prescription (an easy choice because I didn’t have to pay for it) and kept it on hand in case I needed it, but I had only mild discomfort and didn’t feel the need to take anything, not even tylenol. Since I couldn’t have foreseen how much pain I would feel, or whether I would want to take the prescription pain meds, I certainly couldn’t expect the doctor to have foreseen it.

  56. botogol says:

    no personal anecdotes to offer — but perhaps you’ll like this great quote.

    “I ceased in the year 1764 to believe that one can convince one’s
    opponents with arguments printed in books. It is not to do that,
    therefore, that I have taken up my pen, but merely so as to annoy them, and to bestow strength and courage on those on our own side, and to make it known to the others that they have not convinced us.” – Georg Christoph Lichtenberg

  57. BillyJoe says:

    botogol,

    Greetings.

    I thought I recognised the name (I clicked on it to confirm).
    You might remember me offering a different interpretation from yours about what Simon Singh’s words meant when he wrote his article about chiropractic a couple of years ago.
    You might remember that Simon won his case based on that interpretation. :)

    Fancy meeting you here.

  58. botogol says:

    hello BillyJoe – yes he was fortunate! i think the court took a common sense view. He learned quite a lesson though, his writing has been much more evidence based, and his language much less emotional since then.

  59. kulkarniravi says:

    Harriet,

    I do value science and I practice science everyday. My profession (IT) is very unforgiving if I am not logical in my thinking and execution – try being unreasonable with a computer!

    While science is one method of inquiry, I believe that there are other ways. You can poohpooh ancient Indian (and other) wisdom all you want, but the fact remains that they made significant progress with their limited means. Even science needs some beliefs and unfortunately I have seen a dogmatic belief among scientists that theirs is the only way. I try to keep an open mind.

    1. Harriet Hall says:

      @kulkarniravi,
      “You can poohpooh ancient Indian (and other) wisdom all you want, but the fact remains that they made significant progress with their limited means.”

      1. What significant progress are you thinking of? Specific examples?
      2. Did they develop any effective treatments by “spiritual” or nonscientific means? Didn’t they use a rudimentary scientific method of observation, trial and error?

  60. On this forum, I feel like a couch potato coaching Olympians when it comes to debate, because I am genuinely terrible at it. But, I’d like to add a strategy for dealing with a proponent of any belief or philosophy that you would like to disagree with.

    First the disclaimer, this strategy is generally only useful in-person, usually one on one interactions, when the proponent of said belief is attempting to convince you of their belief or engage you in confirmation of their belief. It’s useless in written correspondence and useless when someone asks you a direct question. Also the following may be a complete rationalization for lack of assertiveness.

    So the strategy is – silence.

    Sadly, I have a slow brain. Sometimes when someone brings up some questionable topic I am at a loss for words*. I used to try to offer some sort of amorphous disagreement. This is what you end up with when you can’t recall any of the facts that are relevant to discussion and words like “placebo” escape you. But generally I felt that just offended folks. I like the vast majority of people, I genuinely don’t want to offend. Sometimes I would just unthinkingly laugh uneasily, but often people seemed to take this as a kind of agreement.

    Just as a matter of chance I’ve found when I paused for a long time (Trying to figure out what to say) people react in a different way. Many people are actually are quite in tune and they very quickly realize that silence means that you don’t necessarily agree. Sometime the hard-core folks will just take that as an opportunity to expound further on their pet topic (bummer).

    More moderate people, on the other hand, will often start to cast about for reasons that you might disagree. That is the interesting part, because you can sometimes hear them start to question their rational or move away from a more extreme viewpoint. This often gives you an opportunity to add a rather mild affirmation of one of their guesses, such as “Yah, I’ve always been concerned about the cost of those supplements.” In the end, it seems like the silence sometimes engages the person you are talking to in a thinking process that just telling them what you think doesn’t. The person may “own” that thinking process more.

    Overtime I have developed a range of silences to meet my needs; I reserve stony silences for really appalling statements or jokes, a look of consternation and silence for something I suspect may be dangerous, a small smile and quizzical tilt of the head for something I disagree with but is the speakers own business or a gentle “hum” for someone giving me advice that I’m not likely to take and have no desire to get into a discussion about.

    But of course most of my silences are still “WTF do I say to that?” silences.**

    There, now I can never meet any commentor here in person because you know my code and will be impervious to my silences.

    *Actually, my brain often gives me words, like WTF, hedgehog, Arizona or Barbara Streisand. These are seldom constructive.

    **While other silences are “I’m so impressed with this person, I can’t say a word that seems worthy” or “What kind of hawk is that? or is it a vulture?”

  61. DTR says:

    Check out Obi-michelleinmichigan-Kenobi!

    “These are not the droids you’re looking for” (wave of the hand).

    As one who frequently thinks of the perfect response to an argument several hours after the conversation, I think I might adopt a few of your tactics.

  62. Amy says:

    Thanks Vicki and Greengridgirl! GGG, you may be on to something, he is one to freak out a bit about chemicals. But, I may have to end up taking micheleinmichigan’s view and stay silent, at least for now when he hasn’t gone over the edge, yet.

  63. Chris says:

    kulkarniravi:

    I do value science and I practice science everyday. My profession (IT) is very unforgiving if I am not logical in my thinking and execution – try being unreasonable with a computer!

    That is a similar background to pec. Personally I think the biological sciences are a bit more complicated than computers, so I am more apt to know my limitations.

  64. nybgrus says:

    @ kulkarniravi:

    Thank you for the compliment, it sounded sincere. And no need to suck up.

    As for your article:

    pointed out that the low response rate of 11 percent precluded any generalizations about nutrition-related attitudes and practices of the typical American doctor. But she suggested that, if anything, those who participated in the study were likely to have the most positive attitudes and practices.

    In general, more favorable attitudes toward the importance of nutrition were expressed by younger doctors and by those whose medical training included a nutrition course.

    To try and generalize conclusions for this, when is says in the article itself that you can’t, is a fool’s errand. However, if you do want to take something from it I would look at the fact that “the importance of nutrion [was] expressed by younger doctors…” – that is part of my point. This article was in 1993 and the paradigm for practicing medicine, especially primary care, has definitely shifted since then. In my own studies, nutrition is integrated into every module. We do not have distinct classes such as “Physiology” or “anatomy” – every week we take on a case in a particular system (we just finished GIT after 4 weeks, for example) and everything is integrated into it where it fits it. We look at nutrition and what the effects of malnourishment are, specific deficiencies, excess intake, etc. It is primarily covered in the biochemistry portion of the GIT module. I will try and see if I can come up with an example list of just nutrition topics at some point, but as it is scattered throughout our learning it would be a bit more difficult.

    Having said that, this is where I would agree with you – functional nutrition (i.e. what people actually eat) is probably not stressed quite enough. But that is why there are dieticians. Our role as physicians is to ensure that in general there are no excess intakes, decreased intakes, or diseases associated with that. We also make recommendations for a type of diet (i.e. low fat, high fiber, high protien, more dark green leafy veg, etc). But to come up with a specific plan for someone…. in come the dietician.

    But you must also realize that the vast majority of people (in the developed world of course) very adequately meet their nutritional needs (usually to excess). So there really is very little need for adjustment. Diet is important but it is not a panacea. If you are meeting all your vitamin, mineral, fat, protein, and caloric requirements (and not to excess) then changing your diet around will not do you any particular good. What I am saying is there really isn’t too much an already healthy person with an already healthy diet would gain by making it “more healthy” whatever that might mean. I, for example, eat a LOT of bacon (LOVE bacon) and red meat. Something that would be normally considered a “bad” thing. But my cholesterol is just fine, I weigh 180lbs, and excercise intensely about 8-10 per week. If I dropped the red meat and ate “more healthy” then I either would do very little for myself, or even go into worse health because of the amount of physical training I do.

    So you see, we are taught the basic fundamentals of nutrition, and then apply it to specific patient cases. Drug interactions are important (grapefruit juice being a poten P450 inhibitor, for example). But from a medical standpoint that is all diet can or will do for you. Dieticians take over the rest of the way.

    I am aware of the accomplishments and by no means I am proposing that we throw out all these achievements.

    But then you go on to say how we think we are perfect and make claims about what we do or don’t know. And further go on to claim “other ways of knowing” which are antithesis to our professional ethos. You even implied that a second opinion should be from someone other than a physician. So forgive me if I created a straw man, but I was addressing those points.

    As Dr. Hall has pointed out, if you are on board with all of those advancements and achievements of medicine, then why do you choose to invoke “other ways of knowing” when it comes to your pet likes and dislikes? Such as your CoQ10 story – medical science says that it does not make sense to have cured your PVCs. You say, “It worked for me and you guys didn’t! Ergo, it works and I know it because of my anecdote.” It seems to me you are reasonable and it is where these things get muddy and complex that you become more prone to woo-ish ideas since on the surface it would appear that medicine and science itself is being wishy washy. Part of the package deal with medical advancements is not only accepting the demonstrable and obvious good parts, but also trusting that proclamations of the negative, despite having equivocal results, are indeed negative since both answers and rationals have stemmed from the same process.

    do all the doctors educate their patients of the limitations of modern medicine.

    There is a very fine line to walk there. In my experience (clinical and with actual patients) most physicians I know are quite ready to admit when they don’t know, when the science is uncertain, and to frame the recommendations from the basis of best knowledge available. But think about being the patient being handed a serious diagnosis – you want to be fully informed with all the reasonable caveats, but do you really want your doctor to be a blithering sack of uncertainty? Absolutely not – you would run screaming from the room. So the line between certainty and confidence and accurate skepticism and gray areas must be tread carefully. And just as with Dr. Halls excellent discussion of your codeine prescription may not always be on the mark with what each individual wants. Some people want to be more let in on the fuzziness of the science. Others only want their doctor to get the job done and be a confident ace while doing it.

    Given the gap between the ideal doctor, which you and others on this site project, and the real one which I have to encounter, do you think it is a good idea for patients to do their own research whether it comes to understanding the preventive care or palliative care.

    That is also a double edged sword. Yes, you should most certainly do some research and learn about your condition. The minor risk is that you will not be able to discern the nuanced things leading to accurate diagnosis and go off the deep end. I once had a patient come into the ER and sign in with “malignant hyperthermia and hypothalmic cancer” – I took it very seriously at triage since usually using such distinct medical jargon means the person is well acquainted with their disease. Turns out he had a simple fever and punched in some symptoms and come up with that as a diagnosis and rushed into the ER! The major risk is coming across sites like whale.to or naturalnews or mercola.com – those are nothing but complete and utter garbage but they sound authoritative and would be quite a bad place to try and leanr and do research.

    So yes, taken with a critical eye, sticking to good resources, and taken with a grain of salt patient research is extremely valuable and I would always encourage it. I would also encourage patients to then bring information or studies they are uncertain about to their doctor and ask what it means.

    Think about it – if I did research on legal matters and learned a lot, but ultimately wanted to act on it, I would be very wise to at least run it by a lawyer to make sure I am understanding the law correctly. It is the same with reading health news online. You wouldn’t sue someone without consulting a lawyer but you would take a plethora of supplements and make other important health decisions without consulting a doctor?

    Recent studies have shown that many herbs do in fact have desirable medicinal effects

    Yes, but this field of science is not recent. It is called pharmacognosy and many a good medicine has come from it. The call it CAM is part of the false dichotomy. And the reasons your doctors wouldn’t prescribe such thing are myriad. Part of which is something I and others have discussed at length here – the lack of regulation and the DSHEA. Additionally, there is that “Naturalistic Fallacy.” I would highly recommend you watch Natural Cures by one of my favorite YouTube users to get an idea of why that is.

    Given this, would you agree that lay people study what’s out there and at least partially try to address many common ailments through these more natural means. That’s not throwing the baby out with the bathwater.

    I would agree that they study what is out there and then bring that to their doctor. Watch the above video to understand why addressing ailments through “natural means” is actually overall not the best idea. There is a very good reason why doctors are much more apt to recommend a pharmaceutical over a “natural cure.” I won’t write anymore about it at the moment, but please do watch the video (10 minutes long) and we can discuss that concept further if you wish.

  65. nybgrus says:

    I just read a couple more of the comments, and kulkarniravi I have to second what Dr. Hall said – yes, they were early and spiritual and yes they made advancements. However, did they make those advancements because of and using that spirituality or despite it and using rudimentary science?

    And that is the point – science is not just one specific thing. It is merely a formal description of the systematic way to accurately observe, record, and integrate empirical phenomenon. You do science every moment of your life, it is just on a subconsious level without formally declaring the steps and rigors you go through. And that works well enough for simple things or things related to personal every day matters. But for more complex things (like say drugs/herbs interacting with the human body) it is very much required to have such rigorous scientific thinking.

    You claim you will “keep your mind open” about “other ways of knowing.” We here can describe to you exactly how and why science is the way of knowing. We can tell you where the flaws are, how to overcome them, and exactly how you ultimately get to “knowing.” Can you do the same for any “other way of knowing?” For example, how does “ancient Indian spirituality” help you “know” something or learn something new? Unless you can actually verbalize and demonstrate a single tangible example, then you are better off sticking to science.

  66. pmoran says:

    I doubt if “other ways of knowing” means quite the same thing to K that it means to us.

    Note how K likes to dwell upon perceived limitations to the RCT.

    CAM users have so often had it drummed into them by skeptics that RCTs are the only way of knowing whether a medicine “works” that I believe they now see them as being the primary way that science progresses.

    For them, “science” = ” the double-blind, placebo controlled, randomised controlled trial”.

    This misperception pervades CAM rhetoric, even that concerning cancer therapy, where DBPCRCTs are rarely ever employed other than when investigating symptom relief, but they have nevertheless become a constant object of derision by those who think they know better.

    And it’s totally wrong. The RCTs merely serve to firm up knowledge or theories that derive from elsewhere — sometimes serendipity or anecdotal observations, often nowadays the basic sciences, occasionally historical herbal use, rarely armchair theorisation.

    This is why I suspect that for K and the typical CAm user, anything not RCT-derived can qualify as “another way of knowing”. This makes sense if the underlying objective is mainly to justify, by inclusion, the usual CAM approach to medicine, based upon personal taste, personal research, and trial and error.

    It has little to do with philosophy, New Age or otherwise.

    What do you think, K?

  67. pmoran says:

    Nybgrus:As for Dr. Moran – I honestly have utmost respect for him. He manages to keep much cooler than I do and even though I disagree with what he says a lot of the time, I don’t feel like he is being ideologically obtuse.

    Oh, really? Damn! I am not sure what that means but I’ll try harder. :-)

    Seriously though, I think that medical skepticsm as a field of inquiry is particularly prone to hubris and it needs a shake-up, if not a bit of the piss taken out of it.

  68. kulkarniravi says:

    Nybgrus,

    My entire focus is on prevention. Once you get a disease, say diabetes, there is nothing much you can do in terms of a cure. At best you can sustain life for a long time by dietary modifications, exercise, and in some cases medicine. I am not saying medicine has no place at all, just that it is and should be a small area of focus of healthcare.

    Many herbs, traditionally consumed as staple food, have medicinal properties. If your focus is on prevention, then you would choose a good diet that reduces risk of disease. A great example would be inflammation. If we consume more foods that reduce inflammation one could safely say that one is likely to develop certain diseases. It may not eliminate it altogether, after all there is no cure for death. When I am choosing my diet, it makes a lot more sense for me to take turmeric for example than a anti inflammatory drug. This is a preventive measure, not to address acute inflammation with a concentrated drug.

    There is no doubt that a drug in a herb like turmeric is only there in trace quantities along with a lot of other substances. Perhaps, at least in case of turmeric, it is a good thing. Perhaps they enhance the absorption while reducing the side effects. We can go back and argue about how little evidence there is about the dietary impact on health, but I wouldn’t wait for evidence until I modify my diet.

    As to your final point, all doctors may not have the same enthusiasm for diet modification for health benefits. Besides, they may not even time to study my individual cases in such detail and prescribe me a healthful diet. Tell you what, I have an annual coming up, and I will ask him again about preventive measures. I will update this forum after that.

  69. kulkarniravi says:

    pmoran,

    “And it’s totally wrong. The RCTs merely serve to firm up knowledge or theories that derive from elsewhere — sometimes serendipity or anecdotal observations, often nowadays the basic sciences, occasionally historical herbal use, rarely armchair theorisation. ”

    You have a point.

  70. Harriet Hall says:

    @kulkarniravi,
    “If we consume more foods that reduce inflammation one could safely say that one is likely to develop certain diseases.” One would have to test that hypothesis before one could safely say that.

    Example: Higher homocysteine levels correlate with increased risk of heart disease. Higher levels of B vitamin in the diet correlate with lower homocysteine levels. It seems intuitively obvious that increasing vitamin B intake would lower homocysteine levels and thereby reduce the risk of heart disease. But tests showed that while it lowers homocysteine it does not reduce heart disease risk.

    Science has shown us over and over that we can be wrong and that we have to put our beliefs to the test.

  71. Richard says:

    Oprah and Oz are good at pandering to their audience. I believe we can learn from them and use some of their techniques for good. “You, dear viewer, have the power to choose for yourself. You don’t have to be fooled by the Orwellian newspeak or bait-and-switch of altmed believers and the slick marketing of supplement manufacturers. Be your own person. Research the data and make up your own mind.”

  72. lgehring says:

    Hi, Dr. Hall!

    I’m autistic, and I’ve had some minor success talking to a person who believed autism was caused by vaccines. I started out trying to tell her about all the research comparing autism prevalence between countries (or time periods) using or not using thimerosal in vaccines, differences between the neuropathology of mercury poisoning and what is seen in autism, etc., and got nowhere — she just said that all medical research is funded by Big Pharma, so *of course* they are going to cover up a link between autism and vaccination.

    So I switched tactics. I could no longer talk about autism or vaccination in general, since none of that evidence was going to be admissible for this lady, but I could talk about my own life. My mother had told me she’d noticed differences in me from the very first, rather than noticing a change after I got my first shots. I told her (the lady I was talking to) this, and she accepted it. Just about me, mind you, but she did accept it.

  73. nybgrus says:

    My entire focus is on prevention. Once you get a disease, say diabetes, there is nothing much you can do in terms of a cure. At best you can sustain life for a long time by dietary modifications, exercise, and in some cases medicine.

    I will agree with you that prevention and population health is not given the priority that it should. Having said that, you can indeed cure many diseases, including diabetes. Type II diabetes is “curable” with diet and exercise. Type I diabetes is not yet “curable” but diet, exercise, and medication (i.e. insulin and others) make life quite manageable and long. My 74 year old grandmother has had insulin dependent diabetes for almost 40 years now. She is about as healthy a 73 year old as you can imagine. More to the point, there is nothing you can do to prevent Type I diabetes. All the turmeric in the world won’t make a lick of difference.

    Of course, scientific research can cure Type I diabetes and we have been making strides in gene therapy and islet cell transplantation that could (and I believe will) someday come to fruition and being diagnosed with Type I will be like being diagnosed with pneumonia – here are some pills and an injection, a few days in hospital, and off ya go! But the only way to make that a reality is through diligent application of science. All the ancient Indian wisdom and spirituality in the world won’t get you there – unless you can think of a way that such a “way of knowing” can advance molecular genetics research?

    I find it interesting that you say “At best you can sustain life for a long time by dietary modifications, exercise, and in some cases medicine.” That is all we can ever do. We are all going to die. And we all know that malnourishment, poor diet, and disease will shorten our lifespans. So when your public health programs offer good screens for disease, when your doctor gives you medicine to cure or ameliorate your disease, when you doctor/nutritionist tell you to lay off the McDonalds and Doritos and eat a more balanced diet, and when your country’s infrastructure allows for the delivery of such foods…. that is simply “sustaining life for a long time with….” as you say. It’s just that with the application of science we can accurately measure which of these makes the biggest difference and how and apply them to our populations. That is why the life expectancy of your average person in a developed nation has more than doubled in just 100 years.

    A great example would be inflammation. If we consume more foods that reduce inflammation one could safely say that one is likely to develop certain diseases.

    Dr. Hall said it already – how do you know it is actually decreasing inflammation? And how do you know that decreasing the inflammation actually translates to increased lifespan? Well, for the latter you have already used science to even generate your hypothesis – it was science that told you that chronic inflammatory states translate to increased mortality and morbidity. So why wouldn’t you use science once again to determine if substance X actually decreases inflammation? And once again to determine if that decrease actually translated to clinical outcomes? So many times basic science research looks good in vitro but simply doesn’t hash out in clinical application. That is why we use the science to inform what we trial and then use the trials to confirm (or disconfirm) the idea.

    It seems very straightforward – increased inflammation = decreased lifespan, therefore decreased inflammation = increased lifespan. But inflammation is also the same process that allows tissues to heal – without an inflammatory reaction you would not be able to heal a cut, for example. Without inflammatory cytokines organ and tissue regeneration would be slow or non-existent. So if you completely removed all inflammatory response, you would actually die pretty quickly. So it is important to check what the actual effects of such an “anti-inflammatory” diet actually are. In the case of turmeric (which I cook with often, for myriad reasons) it is likely to be a very modest effect. Worst case scenario is it does nothing, but maybe it helps. I would tell my patients to go ahead and use turmeric if they liked cooking with it and felt it might help them. But to go on and make a claim that it actually would decrease inflammation and thus translate to some tangible health benefit is something I cannot do – unless there is a study to back that up. And we are right back to science.

    We can go back and argue about how little evidence there is about the dietary impact on health, but I wouldn’t wait for evidence until I modify my diet.

    I wouldn’t either. For the first 24 years of my life I had a terrible diet and from the time I was 17 until then I weighed about 240lbs (I peaked at around 255). I changed my diet, started exercising and now I weigh 180lbs and am quite fit. That is a change that the science can inform us on. Making other minor changes (a la turmeric) is completely fine and likely not dangerous, but the science simply isn’t there yet to make such bold claims about what it will actually do for you. No one here is saying diet is not important – and indeed much morbidity and mortality can be prevented through diet and exercise. However, that is for major diet issues like clinical malnourishment, low vitamin intake, excess calories, types of fat and calories, things like that. Because without those things (or with the excess of others) disease processes happen. But once you have a reasonable diet that meets all caloric and nutritional needs without going over, there are vastly diminishing returns. That is the point we are trying to convey. Type II DM can be prevented by diet and we know how. Type I DM cannot. What we are saying is you seem to be pushing nutrition too far and going from Type II advice into Type I advice, if you follow my meaning.

    As to your final point, all doctors may not have the same enthusiasm for diet modification for health benefits. Besides, they may not even time to study my individual cases in such detail and prescribe me a healthful diet. Tell you what, I have an annual coming up, and I will ask him again about preventive measures. I will update this forum after that.

    You are very correct. Part of that is because nutrition in med school and preventative medicine was not stressed enough some decades ago – it is more and more. It takes time to shift such things and some people (yes, doctors are people too) don’t accomodate well to change. Additionally, pressures from society and economy make it more difficult. Whilst many a doctor would love to spend 30-40 minutes with each patient, they simply cannot. First off, they wouldn’t make enough money to pay off student loans. But also, there are simply too many patients and too few doctors to do so. My spending 40 minutes with you means that someone out there either not be seen or have to wait for days, weeks, or months, depending on the back log. I can buck the system and spend more time with my patients. But besides the ethical conundrum that may cause (people going unseen) I simply won’t get paid for that extra time. It may sound petty, but I am anticipating coming out of med school ~$275 grand in debt. When I am a resident I will work 80 hours per week making maybe $60-70k per year. I will have to defer my loans until I make an attending’s salary which will accrue additional interest which will recapitalize on the principle. So by the time I am making real money, I will be 36 years old, have spent 8 years in school plus 6 in residency and fellowship, have ~$400 grand in debt, and just be starting out. I would want to buy a house, maybe have a family, and have general living expenses as well. Think about how much you would need to make if you had an extra house you had to pay for that you couldn’t live in or use and was just a drain on your income. I actually used to work with a doctor who was a hospitalist and he barely made enough money to afford his loans, mortgage, and food for his family. He really wanted to get LASIK surgery but couldnt find a spare $2500 to do it and his insurance wouldn’t cover it. He lived in a modest home, drove a Corolla, and lived fairly frugally so that he could have enough money to put in his 401(k) to actually have something to retire on.

    What I am getting at is that a lot of what your describing is not due to a lack of training or education or even desire on our part. Part of it is doctors are people and not all people are as great and awesome as others. Another (big) part of it is the system is simply stacked against us in that regard.

    But please, don’t blame the science or profession of medicine and appeal to “other ways of knowing.” The one thing that is actually working right is our science and training. It needs to be improved, but so does the system as a whole – as well as society’s priorities in regard to health care and primary education. But I don’t have answers on how to fix that. I just know how I can be the best doctor I can be – by learning the science and conscientiously applying it to the best interest of my patients.

  74. JPZ says:

    @nybgrus

    Wow, can you write a reply! Thank goodness it is cogent and readable as much as it is long. :)

    @K

    I hear your earnest desire to engage in this discussion to learn and teach others in your manner of thinking. From your comments, I do not believe you have a sufficient grounding in science nor a broad enough experience with medicine to draw the conclusions you have so far (although I honestly believe you eventually could with your inquisitive mind). I hope this is not hubris on my part.

    My 9 years of education, 3 years postdoctoral work and 17 years research experience allow me to see science as it grew from simple counting on your fingers, to higher math, to physics, to biology, to systems biology, to psychology, etc (a gestaldt if you will). I can place an RCT in that context and see how it is mathematically, biological, and systematically appropriate – and understand why.

    To equate native belief systems with RCTs is to show only limited knowledge of both (unless you are a shaman-PhD and then could tell us the difference on a fundamental level). Beliefs have a different structure and perform a different role for us than science, and beliefs about outcomes testable by science have more often than not been wrong (in my experience, at a 5:1 ratio in the lab) when tested. Not always wrong, just 5:1 against.

    I also hold the unscientific belief that working with traditional healing methods outside of the context of growing up in the culture is to misuse them. I accept that I could be completely wrong on this.

    My point of view may come from the fact I studied a different field in my postdoc compared to my PhD. I struggled to combine and divide concepts as easily as my fellow scientists. Then, one week, I realized that I “got it” and I could take any new concept and put it into the larger context with ease. This was my first full understanding of the importance of a gestaldt in doing good science. I would guess that a similar step from individual systems to integrated systems occurs during medical school.

  75. nybgrus says:

    @JPZ: I apologize for the long posts – as you may guess it is a topic I am passionate about (perhaps just because I am an eager young second year med student) but moreso, unlike our usual trolls here, K seems to be genuinely interested in some understanding and learning instead of merely blasting us with his ideas. So I got motivated to try and encourage that. :-#

    As to the rest of your points, I agree with your invokation of gestalt. I have pretty significant clinical experience so it is easier for me than most of my classmates, but taking what I am learning and putting it into a wide and deep framework is difficult at the moment. That is a big part of why we train so long. I’ve seen seasoned physicians look at a patient and just from a brief history make a diagnosis – whilst I am struggling to think about the significance of this finding or that test. The attending may not even be sure right away why he decided diagnosis A was preferred over B. It sounds like a guess, but that was because he could see the gestalt of a minor detail and put it into a context that I simply don’t have yet. Then he sits down and starts writing, orders a test, and the whole things falls into place. One day, many years from now, I will be there too.

  76. Anthro says:

    @nybgrus

    Thank you indeed for your lengthy reply. Yes, I have a BA in Anthropology. I went to college in the early 80′s, probably before you went. I didn’t get that nonsense at all. We explored the validity of other belief systems in a class called Myth, Magic and Ritual, but only in the context of cultural respect. The Professor for that class was from Berkeley, but if he was into woo, I never got that message overtly. Looking back, I think he may have been trying to “open our eyes” as it were, to “other ways of knowing”, but if so, it was subtle. Mostly, we wrote long essays attempting to decipher the writings of Claude Levi-Strauss–it was all nonsense, but a good exercise in writing a persuasive essay!

    I truly appreciate the length you have gone to to relate your successes, but I must remind you that you are (or nearly are) a doctor and that makes people listen to you–fence sitters anyway (the hard core will probably not be impressed). You have the scientific background to give specific information. I, on the other hand, while being well-versed in the history of science and familiar with the basic principles, cannot present myself as any kind of expert. I get called on this when I do try to persuade people to even consider an evidence-based approach. I try to get around this by telling the person that I may not know everything, but I do know where to look for reputable interpretation of scientific studies, for example. This usually just brings the inevitable, “science doesn’t know everything” retort.

    Another point is that my friends are not fence-sitters! They are smart (except for science) people who are just as assertive as you or me in defending their positions. I have had some success with fence sitters, but the people I have referred to here are deeply committed to their magical beliefs.

    I’m really sorry to hear about your experience with Anthropology in college. There’s a post on here somewhere about one of the Anthropological professional organizations wanting to “take science out” of the subject! It’s not a majority view, thank goodness, but alarming all the same. We are heading into some kind of Dark Age, I think, which makes it vital to keep trying to reach the fence sitters.

    You have encouraged me to keep trying and I will, but I have to tell you that kulkarniravi’s posts are what I get from my “friends” I don’t know how Harriet keeps on posting her great responses–I get so very weary of it all. I just mentioned in passing, to a friend who has an organic garden (so do I, I guess) that there is no measurable difference in nutrition between organic and conventionally grown food. She went ballistic and has begun emailing me ridiculous articles from all sorts of woo sites. Here we go again. I’d really rather just go out and turn my compost!

  77. nybgrus says:

    @anthro:

    Yes, your anthro days were before mine. However, I stil did have very interesting, enlightening, and worthwhile classes. I was focusing mostly on the negative classes since they comprised such a large part of my degree and since ALL the medical anthro classes I took were like that. It really was a pretty angry ideology with them.

    I think your second paragraph is a compliment, so I’ll take it as such and thank you. However, don’t sell yourself short. Just because you don’t have the specific science background doesn’t mean you can’t otherwise engender critical and skeptical thinking in others.

    As for the “science doesn’t know everything” retort – a tactic I want to try in the future is to then ask 1 of 2 (or both) questions: 1) What exactly do you think science is? and 2) How do you know when your pasta is done cooking?

    The first is a pretty obvious question. The second allows for an opportunity to explain how even the most basic thing is science – we just take shortcuts for simple things. You can then contrast that with “another way of knowing” their pasta is done and show how common patterns can lead to the correct answer many times for simple things, but when you throw in variables you need empirical data and a theoretical framework to predict outcomes – i.e. you need to know the relationship of how much pasta you are cooking to cooking times and eventually you need to empirically take a piece and test it to see if it is cooked perfectly al dente.

    Or something along those lines. I think people just don’t understand what science is – they tend to think it is chemistry or biology or physics. They don’t realize it is merely a rigorous codification of observation and record keeping to avoid bias and can be applied to *anything*. I’ve mentioned it before but I have a book that Vassilly Kandisnky wrote on the usage of form in impressionistic painting. He takes the science of basic shapes and colors and how they tend to be perceived and creates a basic framework for creating impressionist art that is both pleasing to the eye and more than just a paint can knocked over on a canvas. If that can be scientifically studied, anything can.

    But you are right – we can only reach the fence sitters and shruggies. People convinced of an ideology are almost entirely unreachable. But they can also reach the fence sitters. So it really is important to keep that up – as best one can.

    Perhaps with your organic friend ask them to explain why they think organic foods have more nutrients – not links but actually in their own words. And work through how and why that would have the effect they want. You can also show them Penn and Teller demonstrate an <a href="http://www.youtube.com/watch?v=8Zqe4ZV9LDs"organic vs non-organic food taste test with actually granola types :-)

    Just a thought anyways.

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