Jul 18 2008
In Part 1 of this series* I asserted that a physician’s primary ethical responsibility is to honesty and integrity, which in turn must be largely based on science and reason (I apologize if that sounded preachy; if there had been more time I might have couched it in more congenial terms). I mentioned the fallacious reasoning whereby proponents of implausible medical claims (IMC) point to real and imagined weaknesses of modern medicine to justify their own agenda. I offered, as a favorite example of such proponents, science-based medicine’s having not yet solved every health problem. This week I’ll show how this version of the tu quoque fallacy has led a prestigious medical school to advocate pseudoscience-based medicine.
Modern Medicine: a Brief, Fragile Commitment to Science
First, a few more words about the title of this series. Modern medicine is not science, even if it draws upon science for its knowledge: it is an applied science similar, in that sense, to engineering. Modern medicine is also not synonymous with the “medical profession,” if the term means the collection of all people with MD degrees. That is true for the obvious reason that medicine is more than people, but also because a small but loud minority of MDs rejects modern medicine and science.
Modern medicine has made an uneven commitment to science and reason. At its best, it has formally embraced them in the faculties and curricula of medical schools, in its codes of ethics, and in its contributions to knowledge, both basic and applied, over the past 150 years or so. As discussed last week, it is because of science and reason that modern medicine has made dramatic, revolutionary advances in a very short time. That is what distinguishes it from every other “healing tradition,” and why there is no legitimate competition. The only valid medicine in the modern world is science-based medicine—not “allopathic,” “Western,” “conventional,” “regular,” “integrative,” “complementary and alternative,” or any of the so-called “whole medical systems.” The pre-scientific (and, ironically, “post-modern”) designation of “schools” or “systems” of medicine, so stridently trumpeted by quacks, is an anachronism—even if it persists in archaic, governmental edicts.
Compared to the actual sciences, however, modern medicine’s commitment to science is fragile. Its recent confusion of error-prone clinical trials with science itself—the project called “evidence-based medicine”—has been a mixed blessing. Its growing tolerance of charlatans and crackpots, at times elevating them to celebrity status, would be unthinkable in physics or biology. Its dalliances with quackery, so depressingly recounted in recent posts here, here, here, and here, are why your SBM bloggers do what we do. Biologists, other scientists, and intellectuals in general have joined the battle against the pseudoscientific travesty known as “intelligent design.” Many physicians, however, even of the brainy, academic variety, act as though the equally pseudoscientific but more dangerous travesty known as “integrative medicine” is either a good thing or, at least, is a necessary addition to medical school curricula.
The Case of Yale Medical School and David Katz
Yale Medical School provides a disturbing example. It has a new ”integrative medicine” program that touts the usual advertising slogans, including the vision of ”an integrative healthcare system that combines the best evidence-based therapeutics from both conventional and non-conventional medical systems.” It has joined the Consortium of Academic Health Centers for Integrative Medicine, a beneficiary of the wealthy Bravewell Collaborative, whose commitment to mandating quackery in all of medicine has been discussed several times on SBM. Some of the “people” in the Yale program are the conspicuous woo-meister Bernie Siegel; the lesser-known woo-meister David Katz, Director of the Yale Prevention and Research Center; and a naturopath who graduated from Bastyr University.
In April, the program hosted the 1st Annual Yale Integrative Medicine Scientific Symposium. After a full day of pablum and nonsense, the symposium came in for some well-deserved criticism, especially here, here, here, and here. It was directed mostly at two participants: Yale’s Dean of Medical Education, Richard Belitsky, whose obsequious welcoming statement had betrayed either an ignorance of science and critical thinking or an ignorance of “CAM”; and David Katz. Katz had given a talk in which he presented several disconfirming trials of IMCs and concluded that “it’s an invitation to think more fluidly about evidence.” Curiously, he had previously authored a book titled Clinical Epidemiology & Evidence-Based Medicine: Fundamental Principles of Clinical Reasoning & Research.
I recently gave a talk on evidence-based holistic care at the Yale School of Medicine’s inaugural conference dedicated to ‘integrative medicine,’ generally defined as the blend of conventional and alternative medical practices. This is the model we use at the Integrative Medicine Center I run in Derby, CT (www.imc-griffin.org). I was subsequently branded a quack in certain quadrants of the blogosphere. So I am writing a defense. But not of myself, nor of my talk, nor of Yale, nor the conference. But of patients.
The view I expressed, and that guides our practice, is that human need goes on long after the results of randomized clinical trials start to run thin. I do not think doctor and patient should part company there. I believe that responsible use of the science we have should not preclude responsiveness to the needs of patients that fail to respond as textbooks say they should to that all-too-limited science. I believe, in other words, that patient need, not trial results, should be the ultimate master medical care must serve.
I learned devotion to evidence-based practice from my teachers and professional colleagues; I was pushed toward integrative medicine by the needs of my patients.
Some, apparently, see quackery in a willingness to try to help a patient feel better past the point where scientific evidence is decisively clear. But does it actually make sense to subordinate patient need to the limits of what we know with certainty, when what we strive to know through biomedical research is all in an effort to satisfy patient need? If so, I suppose I would rather be a duck than a doctor, so claims of quackery are just so much water off my back.
By Sleight of Pen: Language Distortion is Power
Many readers of that passage, even those in academic medicine, might fail to recognize its subtle language distortions. “Trial results,” “science,” and “what we know with certainty” are casually presented as interchangeable terms, with the tacit presumption that none would disagree. It follows that the limits of science are found when “the results of randomized clinical trials start to run thin.” Of course, “what we know with certainty” is “all-too-limited.” Who would disagree with that? The toolbox of a practitioner constrained by ”science” must be very small indeed.
It also follows that in the much larger realm of practices outside “that all-too-limited science,” there is no basis for distinguishing one from another. Since science has nothing to say about them, all are equally promising. All are thus fair game for the practitioner “pushed toward integrative medicine by the needs of [his] patients.”
In clinical situations where trial results do not provide clear guidance, the only alternative to “alternative medicine,” says Dr. Katz, is to abandon the patient. Such a ”when did you stop beating your wife” argument is insulting to all honest physicians, who either know or ought to learn how to deal with such situations without sacrificing their professional integrity.
What, exactly, is in store for Dr. Katz’s patients when “the results of randomized clinical trials start to run thin”? Obligingly, he directs us to the website of his Integrative Medicine Center at Griffin Hospital in Derby, CT. In addition to Dr. Katz, who refers to himself as a “nationally renowned authority,” the Integrative Medicine Center Team includes two naturopaths, a nurse practitioner who specializes in Therapeutic Touch, and a young MD from Pakistan who, having won a gold medal for being the “top medical graduate” from Baqai University, derailed an apparently promising career by selecting Griffin Hospital for his internal medicine residency.
If it Walks Like a Duck and Quacks Like a Duck…
“Treatment approaches available at the IMC include”:
internal medicine, naturopathic medicine, preventive medicine, nutritional counseling, nutritional supplements, nutriceuticals, herbal medicine, acupuncture, craniosacral therapy, Therapeutic Touch, homeopathy, intravenous micronutrient therapy (Myers’ Cocktail), relaxation therapies, as well as referrals to counselors, trauma therapists (EMDR), and chiropractic.
The links above, which I added, demonstrate that contrary to Dr. Katz’s assertions there is plenty of science—trials or no trials—pertaining to the corresponding methods, and that science convincingly demonstrates each to be bogus. The most obvious example is homeopathy, which is as valid as a perpetual motion machine and just as deserving of a trial. “Myers’ Cocktail,” an intravenous infusion of calcium, magnesium, and several vitamins, has all the characteristics of snake oil. There is no reason to predict that it would benefit anyone not suffering from a frank deficiency of one or more of its ingredients, the combination of which is arbitrary. All are easily absorbed through the GI tract, thus raising the question of why they are given intravenously, which is both more dangerous and more expensive than a pill.
The obvious answers are two: the “placebo effect” is enhanced by the invasive procedure, and it is more lucrative for the quack. The Myers’ Cocktail champion, Alan Gaby, a former faculty member at Bastyr University, promotes it as a near panacea:
Conditions that frequently responded included asthma attacks, acute migraines, fatigue (including chronic fatigue syndrome), fibromyalgia, acute muscle spasm, upper respiratory tract infections, chronic sinusitis, and seasonal allergic rhinitis. A small number of patients with congestive heart failure, angina, chronic urticaria, hyperthyroidism, dysmenorrhea, or other conditions were also treated with the Myers’ and most showed marked improvement. Many relatively healthy patients chose to receive periodic injections because it enhanced their overall well being for periods of a week to several months.
If Dr. Katz lacks the street savvy to recognize the concoction for what it is, he might consider the results of his own trial of the Myers’ Cocktail for patients with fibromyalgia. Although his 2006 abstract tortures the data to suggest efficacy, none was found. Since the treatment is implausible in the first place, this amounts to pretty solid evidence against it. Nevertheless, nearly two years later Dr. Katz still peddles Myers’ Cocktail at the IMC, or so we gather from the website. He must have “thought more fluidly about the evidence.”
Thus by distorting language in order to bait and switch, Dr. Katz and Yale University have transformed “responsiveness to the needs of patients that fail to respond…to that all-too-limited science” into that all-too-familiar, all-too-unlimited quackery. Abracadabra!
Next Week: If not the logic of Katz, then what?
* The Science, Reason, Ethics, and Modern Medicine series:
Science, Reason, Ethics, and Modern Medicine Part 1: Tu Quoque and History
Science, Reason, Ethics, and Modern Medicine, Part 3: Implausible Claims and Formal Ethics Statements
Science, Reason, Ethics, and Modern Medicine, Part 4: is “CAM” the only Alternative? And: the Physician as Expert Consultant
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