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Science, Reason, Ethics, and Modern Medicine, Part 2: the Tortured Logic of David Katz

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 herehere, 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.

Dr. Katz, who can serve up tu quoque and PoMo drivel with the best of them, responded to his detractors with the “medicine doesn’t know everything” ploy:

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 2: the Tortured Logic of David Katz

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

Science, Reason, Ethics, and Modern Medicine, Part 5: Penultimate Words

Posted in: Health Fraud, Medical Academia, Medical Ethics, Science and Medicine

Leave a Comment (41) ↓

41 thoughts on “Science, Reason, Ethics, and Modern Medicine, Part 2: the Tortured Logic of David Katz

  1. Michelle B says:

    Excellent post!

    Katz is palming his sloppiness off as care and concern for patients, while he is implying that setting parameters for care is equivalent to not caring. What a disgusting doofus.

    The writers at this site are heroes for our times.

  2. llysenwi says:

    So, what do we do about this? How can we make universities say no to the money the Bravewell Collaboration throws around? Dr. Novella has said that he is fighting the integrative medicine forces at Yale, but what can the rest of us do?

    My undergraduate alma mater, Duke University, mortgaged the integrity of its medical institutions in 2000 with the Duke Integrative Medicine (DIM) center (funded by Bravewell), which offers acupuncture, guided imagery, oriental medicine consultation, reiki, and spiritual counseling, along with a host of other modalities on their a la carte (their term not mine) menu.

    Since what seems to make a difference to the university presidents and heads of medical centers is money, not reason, I have decided to inform Duke of my intention to never make an alumni donation to the school while the DIM is in operation. I am currently composing a letter to this effect (any suggestions/references to support the scientific position would be appreciated).

    The influence wielded by university alumni is disproportionately strong relative to their individual donation amounts because alumni provide a continuing income stream (as opposed to one time boluses of money), can influence other alumni donation practices, and alumni donation levels are a factor in university rankings.

    Maybe having segments of alumni voicing their disapproval with their pocketbooks will finally get someone to listen and it literally costs nothing more than a stamp to do. Thoughts on the quality of the concept?

  3. Harriet Hall says:

    Katz has set up a ridiculous straw man. Scientific medicine, in the hands of good clinicians, is responsive to the needs of patients. Even when it can’t offer a cure, it can offer relief, palliation, and hope.

    He seems to think he knows what patients “need.” How can he be so sure? And why can’t he satisfy those “needs” without resorting to nonsensical treatments? Isn’t it demeaning to patients to think they “need” us to play make-believe?

    He seems to be saying that “anything goes” as long as patients say they feel better. I would feel better if the clinic provided me with a personal maid or gave me money for a shopping spree. When you reject science as the standard, where do you draw the line?

  4. David Gorski says:

    He seems to be saying that “anything goes” as long as patients say they feel better.

    There’s no “seems” about it. That’s exactly what he’s saying:

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

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

  5. daijiyobu says:

    What I like BEST about Bastyr — and I find it delightfully appauling — is this statement, see http://colleges.usnews.rankingsandreviews.com/usnews/edu/college/directory/brief/drmiss_22425_brief.php :

    “Bastyr’s international faculty teaches the natural health sciences with an emphasis on integrating mind, body, spirit and nature,” with nature of course meaning vitalism.

    I wish I could take out a US News ad for things I can’t deliver upon, and THRIVE without penalty.

    Which reminds me of the University of Integrated Science California, here http://www.uisca.org/en/content/default.asp :

    that states “spirit: an orphaned branch of scientific investigation; the most central and material of being.”

    Huh?!?!?!?

    Complete science-illiteracy, galore.

  6. llysenwi, there are many things people can do to fight quackery. First, focus narrowly, then investigate, get the facts, comunicate them by targeting your audience which means knowing who it is and speaking its language.

    Send letters to specific publications like alumni newsletters, institutions and local papers. In rural areas of the US and Canada local papers still have a strong voice and they are read by reporters from the AP and regional publications who often pick up and write about what they find in them. Their stories are in turn picked up by the national and international media. Also do webpages or blogs specifically targeting the topic you have chosen to expose.

    Will you win the war? Probably not and certainly not any time soon, but if you do it right, you will make a difference. You will get your message to a lot of people and the mainstream media will pick it up. You may also be asked to be a consumer advocate on a board where you will have some positive impact.

    But you have to focus, have your facts down cold, be passionate when talking to the general public and speak out to get anywhere. It is amazing how much one person can do, but the more people who take this on, the better the chance of winning the war and of winning it sooner rather than later.

    I have learned this from experience. If I can do it, just think what people here with far more brains, credentials and talent than I have can accomplish!

  7. RickK101 says:

    I’ve recently joined this blog after listening to SGU’s podcast. After reading many of these posts, participating in some discussions, reading about the Bravewell Collaborative, and most recently reading the list of universities with CAM schools, I’m feeling more than a little disgusted with our country and its education system.

    In a moment of depression, like now, I can’t help but think that maybe we should just stop fighting and let CAM have it’s way. Let people waste their money. Let the credulous ones shorten their lives through ineffective medicine.

    Eventually CAM will get big enough that it is no longer seen as a scrappy bunch of rebels, but as the massive profit-generating business it is. Eventually HMO oversight of CAM treatments will force practitioners to do more with less time per patient. Imagine for example how quickly Reiki will collapse when the HMOs will only cover a rushed, 10-minute visit.

    If CAM gets big enough, it will eventually take on all the negatives of “big, heartless, science based medicine”, and people may actually start to miss the one major benefit of SBM – treatments that work.

  8. overshoot says:

    These programs can be very useful. No, wait! Really! Please read the rest!

    I say this in my role as a hiring manager who is familiar with some of the, shall we say, less than top-tier faculty in our local University’s electrical engineering program. One of the litmus tests I use to screen applicants from said program is to ask them what they think of those faculty and their (mandatory) pet programs. If I get a positive response, I know I’m dealing with either a blithering idiot or a bullshitter; either way I can stop wasting time on hir and hope s/he goes on to a long career with the competition.

    The same should apply to graduates of, for instance, the University of Arizona or Yale. Ask the recent graduates their opinions of the pioneering work done by Andrew Weil and his fellow-travellers. Listen carefully. Act accordingly.

    See? These programs really are very useful.

  9. jwittner says:

    Man I love this blog.

    I had more to say, but the previous comments hit most of it. So I’m just going to stick with that.

  10. DBonez says:

    Okay, I know this wasn’t a Weekly Woo W^5/2 article, but I couldn’t help thinking this quote sounded so ridiculous that it might also go something like this. . .

    “Conditions that frequently responded [well to The Myers’ Cocktail] included flustered, blah, dismal, icky, spun, oogy (including chronic oogy syndrome (COS)), loopy, floaty, gnarly, off-kilter, spacey, and yucky. A small number of patients with chronic funk, a moderate to sever case of the heebie-jeebies, grody syndrome, a bad case of the far-outs, someone who is completely whacked-out, near terminal cases of being gorked, or other conditions were also treated with the Myers’ and most showed marked improvement up to and including feeling warm-and-fuzzy and even bodacious. Many relatively healthy patients chose to receive periodic injections because it enhanced their feeling of twitterpation and giddy for periods of a week to several months.”

    I just couldn’t help it. Excellent post as always.

  11. Wallace Sampson says:

    Laurels to Kim A. again. His command of the field is remarkable and as usual, there is little left to say after reading this post. But to support those above, and Steve’s July 16 post also,

    I practiced and taught cancer medicine for 35 years. I lost a few patients in the early Laetrile days when the L people trashed medicine as part of their sales pitches (“Cut, burn, and poison…”)

    But soon, when approached about anomalous therapies, I learned to be direct and even a bit judgmental, but in a way that did not insult patients, and was able to serve the needs of those patients without ever doing quacky or referring a patient to quackery (or altmed….etc.) even to the point of serving as a source of narcotics only for those who rejected cancer-directed medicine – and using stuff from prayer to herbs and hand-waving.

    Practicing under those conditions brought up ethical dilemmas such as the need for hospitalization when appropriate treatment could have avoided it, unnecessary complications including pathological fractures, transected spinal cords, protracted nausea and vomiting, and the gamut of nightmarish conditions we had learned to prevent or to postpone until terminal days through judiciously applied effective medicine. To say little about the cost of caring for people opting into the nether world of pseudoscience and belief. My last 10 years in a public supported university-associated hospital and clinic precipitated the dilemma of a supporting personal denial systems at the public’s expense. (Insurance payments of course are another form of same.)

    But the point is that sectarian systems and denial present physicians with dilemmas but not with the falsely constructed on/off switch of doing it or not. MDs who practice anomalous medicine I am certain have personality disorders, are borderrline or frank intellectual psychopaths, and should not be practicing.

    What is one to do? Jstan helps. Speak up and out. Stand firm. Write for papers and magazines (and medical journals.) Call med school departments and ask what th’ they are up to.

    W Sampson

  12. llysenwi says:

    While I appreciate the encouragement of rjstan, my frustration is with that we have no organization in the fight against CAM.

    This blog, Neurologica, and Quackwatch have made a good start, but these are mostly going to people who already agree with each other. The opposition is organized. That is why CAM has made so much headway in medical schools. We are not. Individually, we have no chance on a large scale if we have to reinvent the wheel each time.

    Similarly, pro-ID and Creationist forces were organized and making headway. The NCSE, for example, has done a lot to organize opposition. Importantly, they have made expert knowledge available to non-experts in usable forms. They have provided venues to further cooperation and make the community aware of issues as they arise.

    Analogously, one can look at the rise of fundamentalist religions compared to atheism and moderate religions. The fundamentalists do not have a better message, but they are dedicated and organized, while their opposition is not.

  13. The opposition isn’t merely organized. It is a billion $$$ business that has employees, some of whom may well be hired to monitor this forum and even try out marketing techniques and damage control here. It is a business that spends large sums of money marketing its products and researching the best ways to market them just like every other successful business does. It is not about “woo”. It is about money and convincing the public anyway it legally can that it needs to buy its goods and services. That is the first thing that any individual or group needs to realize that hopes to make a difference. Second, they must understand that the industry’s biggest source of revenue, the fuel that runs the entire billion $$$ multinational alt. machine, is “dietary supplements”. The best supplement marketers are in the botanical business. They are brilliant and just as rational and well versed in logical fallacies as any Skeptic. The only way to keep them from deceiving the public (or is that marketing their products?) is to investigate supplements, learn the facts and make them public. Don’t fall for that garbage, “MDs know more about pharmacology than I do, but I know more about botanicals than they do.” BS. If it has active ingredients, the ones who know about it are pharmacologists and I’m sure that many of the MDs here know pharmacologists who would be more than happy to educate them if the need were to arise.

    Of course, it would be wonderful to have a group to work with, but it has to be the right one or it will do more harm than good. Till then, each of us does what he can. Based on my personal experience I think that one person can make a difference. I think I have made a difference. How much? I don’t have any idea. I wish I could hire a marketer to gauge that. Many of you might think that I have gotten media coverage because I am a freak. You are right. I am a freak, but that is not why I’ve gotten media coverage. I’ve gotten that because I have an interesting, newsworth story to tell and I have the evidence to substantiate it. That evidence includes my face, a visual that TV loves.

    I’ve done interviews on Good Morning America, a syndicate that feeds local stations across the US which they say totals 80 million viewers, CNN, several local CBS affiliates, 2 Discovery Channels. Univisión, a German station, Ripley’s Believe It Or Not. And there may be others that I’ve forgotten. I don’t keep track and try not to look at anything I’ve done because I hate to see myself and have no control of the way the material is edited and presented. Two more TV interviews are in the works. I’ve gotten email from all over the world from people who have seen me. I’ve been featured in articles by the AP, Newsday, The Globe & Mail and many small publications and quoted in the Wall St. Journal and the New Yorker. Those are the ones I know about. Others pick up the story and repeat it. It has been repeated on the radio and even in a tabloid. I wrote “my story” for a dermatology journal at the editor’s request since the journal now includes some “human interest” stuff. My webpage has been referenced in several medical journals and even in a microbiology journal in an article by a microbiologist who is a consultant to the silver industry. Thanks to Bruce Bouts, an MD and also a pharmacist, my case was reported in the NEJM. Bruce was the first MD to step up to help me and agree to speak to the media. He has spoken on camera and also acted as a resource.

    I won’t go into what I’ve done legally because I hope you get the picture. If I could do this, the chances are very great that several people reading this can do as much or more. It isn’t easy and it isn’t fast but it can be done.

    I haven’t come close to winning the war and I’m not finished fighting, but I have learned a bit about getting the message out and will be glad to share my experience with any good people who want to hear. If anyone is interested, write me privately. rjstan@together.net

    I will not give details here for quacks to read.

    The most difficult thing for those fighting quackery is that we see our failures, the people we did not reach. They have names and faces. We don’t see the ones who heard our warnings, took heed and weren’t killed, injured or robbed as a result. They are anonymous even though we know statistically that they must exist.

    I’m sorry to preach, but I feel there is incredible talent here along with good intentions but that some direction and focus are needed.

  14. Dr. Samson asks, “What to do?” To start realize that this is not about irrational beliefs. It is about $$$$$! The silly babble is to mask that. It is marketing spin. The important alt players are brilliant and as rational and well educated as the best of you are. They are brilliantly exploiting social situations to make an easy buck. Get out into the trenches and see what your ordinary MD trying to practice responsible, not even EBM, is up against today. Look at his workload, level of stress and income. Do the same for medical institutions like hospitals, med schools and health care agencies. You can squeeze just so hard before something gives. Brilliant alts have found a way to easily exploit this. They use deception to convince customers that they can deliver what the customer wants for very little cost without any of those nasty side effects of scientific medicine.

    Where does the bulk of your average alt’s income come from? Supplemetns. Supplements are the fuel that powers the machine. There are brilliant people in the supplement industry who know this. They support and promote all alts because they know how good alts are for their own bottom lines.

    The disease is greed not woo. There is little hope of finding an effective treatment for it until you correctly diagnose the disease.

  15. Fifi says:

    rjstan – “The disease is greed not woo. There is little hope of finding an effective treatment for it until you correctly diagnose the disease.”

    Well said, and when the immune system is weak or wounded (as in a damaged or never developed ability to think critically) – or is already infected by fear, greed, loneliness – then the disease can easily take hold.

  16. PeterHansen says:

    Dr. Katz is more dangerous than any naturopath or homeopath. By combining pseudoscience with science he blurs the line. He gives credibility to the pseudoscience, and nobody in the public can be expected to know the difference. Even physicians who normally have critical thinking skills will tend to put those skills aside when listening to a colleague.

    Remember, most schizophrenics are very articulate. Most that I have met have been confident and intelligent. It’s only when they say their ideas came from a satellite through their TV that we realize they are crazy.

    More subtle forms of delusions are more difficult to see.

    (Delusion: something that is falsely believed or propagated.)

    To continue to believe in a treatment despite excellent evidence to the contrary is delusional.

    I realize its a stretch, but when I have someone in the office suffering from a delusion, and is a significant risk to others, we do a 72 hour hold. What should Dr. Katz’s personal physician do?

  17. Fifi says:

    Peter Hansen – You make a good point about delusions and schizophrenia. While there are certainly people who are just defrauding the public, there are also those who believe fantastic things because they are suffering from a neurobiological condition that makes it difficult (or impossible) to distinguish fantasy from reality.

    That’s why alien abduction, Satanic child abuse (which is not to deny child abuse, it’s just not a supernatural phenomena), evil lizard overlords and paranoid conspiracies get traction – they confirm a paranoid schizophrenic’s beliefs and experiences. There are also certain aspects of bipolar disorders and having grown up in certain kinds of abusive environments that result in people having poor boundaries and an overly developed sense of empathy or ability to subconsciously read others (developed as a defensive mechanism). By an overly developed sense of empathy, I mean that they no longer have a good understanding of their own psychic boundaries (by psychic, I don’t mean magical or supernatural, I mean the boundaries of one’s psyche and knowing which emotions are one’s own and which one’s are a form of transference). This can lead to people feeling like they’re psychic since they don’t understand the source of their “knowing” and presume a supernatural explanation. It’s kind of obvious why people prefer to believe they’ve got magical abilities than admit that their grip on reality is stretched a bit thin – there’s a very profound fear and stigma regarding mental illness. It’s also kind of obvious why they’d position doctors, society at large and science as “the enemy” – not only is there the paranoia in some cases but there’s also the desire to avoid coming to terms with the emotional/mental illness. And, of course, those who have psychotic episodes where they pose a danger to others or themselves have probably spent some time in a hospital or mental health facility. Personally I don’t take any issue with someone believing wacky things if they’re not hurting or exploiting others (knowingly or just as a means to affirm their own beliefs) – and most people who are bipolar and schizophrenic are lovely people who have no violent tendencies, they’re simply victims of their own biology and deserve our compassion. Compassion doesn’t mean supporting and feeding their delusions, of course.

    A lot of what is promoted as supernatural in a religious/new age/energy medicine context has such traction because people have subjective experiences (which are natural in origin) that they then explain to themselves in a spiritual/supernatural framework. Most of us are prone to having these experiences, some of us more so than others depending on our neurobiology, and obviously specific drugs can create specific kinds of “mystical” experiences.

  18. pmoran says:

    Schizophrenic delusions? Do try and understand what is happening here.

    The conviction despite contrary evidence that inactive treatments are having potent effects on illness can be due to self-delusion, but it can also be due to a misunderstanding of the reason for genuine patient benefits. I myself have observed *some kinds of illness* to almost magically disappear after a little explanation, reassurance, simple advice and token “treatment”. I am therefore prepared to believe that despite some proneness to exaggeration and possible observational biases, “alternative” testimonials and anecdotes are probably not all hot air. It is the mistaken attribution of the outcomes to almost certainly inert treatments that is at fault.

    There is nothing mysterious about all this. People are very suggestible and they can switch attentiveness to symptoms on and off. It is part of what we dismissively and rather inaccurately call “placebo effects”, We don’t detect such happenings in normal scientific study because the benefits of reassuring, nurturing medical contact are controlled out of existence. This also applies to some extent to the Hrobjartsson study, which is touted as showing that the placebo complex of influences isn’t worth worrying about. The relevant science is not this study, but the Kaptchuk one suggesting that sham treatment can have vastly different apparent “effects” depending on the “schtick” of the practitioner. These two studies have been discussed in previous posts on this blog.

    Katz is thus very wrong in his inability to see the clear pattern throughout medical history and also within “alternative” medicine itself of literally hundreds of unlikely treatments being falsely thought to have therapeutic power. He cannot yet grasp why methods that seem to “work” in practice fail to perform in studies where practitioner “schtick” is eliminated by appropriate controls. He is looking for answers in the wrong place.

    We are almost as wrong if we fail to appreciate fully why this kind of thing happens all the time to honest and fairly sensible doctors trying to do their very best for their patients. They are not necessarily anti-science — they are trying to deal with an existential conflict that we could possibly help them resolve if we ourselves were only completely open as to what the science allows. One hurdle for communication is the reluctance of the critics of alternative medicine to credit the allegedly pseudoscientific practitioner with offering any benefits at all to his patients. The practitioner “knows”, with every fibre of his being, and probably quite correctly, that he IS helping some patients. Another hurdle is the failure to sufficiently appreciate that illnesses comes in all shapes and sizes, and in many the psychosomatic elements are far more important than pathophysiology or pharmacology.

  19. cinderkeys says:

    As someone who knows people with CFIDS (aka chronic fatigue syndrome), fibromyalgia, and multiple chemical sensitivities, I can well imagine how the quacksters drum up business. Many legit doctors turn people with these disorders away, assuring them that what they have is all in their heads. (CFIDS, fibro, and MCS are all quite real, and very serious, but a lot of physicians don’t seem to have gotten the memo.)

    So, patients turn to the alt.doctors, who are nice to them and don’t treat them like they’re crazy for believing their real symptoms are real. CFIDS patients, sadly, tend not to respond as much as the general population to placebo effects (not sure about fibro). But I could see them coming back for more attempted treatments anyway, just to see someone who is at least taking them seriously and TRYING to help them. And, oh yes, talking to them for more than ten minutes at a time.

  20. Fifi says:

    pmoran – I was speaking generally about people, not about Dr. Katz (I have no idea about his mental state!). My experience (and this is obviously anecdotal) is that most people who believe in various superstitions and/or things like energy medicine (and I’m not claiming immunity from superstition for myself!) are quite sane and have quite legitimate emotional/psychological reasons and an internal logic for coming to the conclusions they do (subjective experience is VERY convincing!). That said, I also have friends who’ve had psychotic breaks that they confused with being enlightened or a supernatural state (fortunately, and happily, they all sought treatment and have found way to make peace with their own minds and neurobiology). I’ve also had experiences that FEEL like supernatural events – I meditate so I’m quite familiar with the states induced by meditation, I’ve done drugs that induce certain “mystical” experiences, and I’ve experiences sleep paralysis. Most beliefs about supernatural energies/beings/states have a basis in experience of some kind, they just mistake causation and project a narrative or meaning onto it because of the mistaken causation. I’ve got one or two friends who know rationally that certain beliefs are superstitious (and can admit it to themselves and others), they just prefer to believe in a nurturing/protecting supernatural presence (though not to the exclusion of science nor are they seeking to replace science or bend science to support their faith, and they all take exception to pseudoscience and people who try to use it or religion to exploit the innocent).

  21. Peter H, “Dr. Katz is more dangerous than any naturopath or homeopath. By combining pseudoscience with science he blurs the line. He gives credibility to the pseudoscience, and nobody in the public can be expected to know the difference. Even physicians who normally have critical thinking skills will tend to put those skills aside when listening to a colleague.”

    That is all true, but Katz is just one of a great many doing that in the mainstream media, in med schools, hospitals and, in a word, in what used to scientific institutions.

    I don’t know Katz. I don’t know why he is doing it. But I have known several alt practitioners and true believing alt users who are sincere, good, caring, honest people who simply don’t understand that because one thing follows another in time that it doesn’t necessarily mean that the first caused the second.

    I’ve also known alts who I am certain have very serious mental problems and with some of them you have to converse with them for quite awhile to discover this. (There is one who believes my webpage is a front for a secret military organization engaged in psychological warfare and that federal agents follow him around recording what he says. I don’t know about the feds, but I am absolutely certain there aren’t any soldiers in my Mac.)

    My theory, and it is just a theory because I don’t have the money to investigate properly, is that irrational beliefs have and always will be with us. But about 10 years ago very brilliant marketers discoverd that they can water most of them down, repackage them and make a fortune selling them in the mainstream marketplace. Some may even consider this harmless or better yet beneficial. I do not. I think it is exceedingly dangerous.

    Perhaps someone can help me state this better. Psychiatrists say that when a group holds an irrational belief it is cultural. When an individual holds one, it is delusional. I’ve never been able to get anyone to pin down the # of believers that causes psychiatrists to move a belief from the delusional to the cultural category. About 10 years ago, we saw marketers start moving irrational beliefs held by the lunatic fringe into the mainstream. They developed products that they claimed offered health benefits to sell in the mainstream marketplace where the real money is. Example: homeopathic “remedies” went from health food stores to supermarkets and drug stores. It worked from the bottom up and now it has reached medical schools. That was the game plan. They had to get to respected institutions so that their products would look legitimate and so that they could get third parties to pay for them which I predict is next on the alt agenda.

    Katz was quoted as saying, …”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. ”

    When I hear that, I think, “Sell the customer what he wants.” As I said, I don’t know Katz. He may see human misery and think he can go beyond science and help people “feel better” or even “be better” by getting them to eat well and exercise. I have no idea. What I find ironic is that for most of the history of civilization people used organized religion to help them feel better, to help them make sense out of and cope emotionally with a very cruel, unjust world. Not long ago they replaced religion with psychology. Now it seems that that has been chucked for “medicine”. Now your doctor be he alt or integrative is supposed to solve all your problems and make you happy without prescribing a nasty synthetic drug that is. He is supposed to have all that he needs to lift your spirits – music therapy, art therapy, good nutrition, exercise, marvelous health. He will channel your energy, pray with you, lay on hands, counsel you and take your money too.

    When this Great Medicine Man fails, who do you go to next? A lawyer? A reporter? A magician? A psychic? Your grandma? Maybe it will be back to God again. Maybe he will be the one who will solve all of your problems all of the time or for a little while at least.

  22. About 10 years ago, we saw marketers start moving irrational beliefs held by the lunatic fringe into the mainstream. Who ever heard of a naturopath or a homeopath 15 years ago? They were in the backwoods. Then they became “doctors”. “Colleges” offered degrees. Some states licensed them. Now they are in what used to be scientific institutions in a white coat just like the MDs and their “remedies” are sold in the drug store. Now that is integration!

  23. overshoot says:

    My theory, and it is just a theory because I don’t have the money to investigate properly, is that irrational beliefs have and always will be with us. But about 10 years ago very brilliant marketers discoverd that they can water most of them down, repackage them and make a fortune selling them in the mainstream marketplace. Some may even consider this harmless or better yet beneficial. I do not. I think it is exceedingly dangerous.

    If you want to get a swing going really high, you push it in the direction it’s already going.

    I’ll propose an alternative: during the 20th century, and especially around the middle of it, the public in Western countries had great hopes that science would lead to Utopia Real Soon Now. We would conquer all disease, even death; we would have flying cars; we would all live lives of wealth and ease. For a while, especially in the United States, that dream seemed to be on track. Whole generations (can you say, “baby boomers?”) grew up expecting that that would be their birthright.

    Imperfections like the Cold War, the threat of nuclear devastation, and the Vietnam War weren’t just bad in their own right but because they were a violation of the promised birthright. The children of the Boomers grew up expecting that they would start off even wealthier than their parents, who in turn had expected to start their adult lives as well off as their parents were after decades of work.

    And science let them down. Never mind that smallpox is extinct, polio on its way; infectious disease is icky and doesn’t happen to us anyway. Except for HIV. And SARS. And bird flu. And West Nile. Science doesn’t work.

    Now the SUVs are too expensive at the price of gas — and whose idea was that? The economy hasn’t turned us all into kings, and we still have to go to work, if we have jobs, and space travel hasn’t got us the Enterprise and there aren’t any flying cars.

    Science is a failure. It’s time to believe in something else that promises us Utopia, and we want it NOW damn it!

  24. overshoot says:

    Oh, and I forgot to mention:

    Correlation isn’t causation, but track the popularity of woo against the sales of wrinkle cream and foundation garments to Baby Boomers. It’s hard to reconcile the Flower Children of the Summer of Love, with dreams of Sex, Drugs, and Rock and Roll with those sagging boobies and the little bottle of Viagra in the bathroom.

    And Science isn’t promising to bring back the all-night orgies (even if we never managed to find them, the Dream was there.) So it’s time to move on to someone who does.

  25. angel12 says:

    Well definition of modern medicines. I am agreeing with you. I think doctors should consider humanity first in treatment.
    __________________________________________
    Angel
    Addiction Recovery North Carolina

  26. Fifi says:

    No offense, while I like to blame the Boomers and that generation’s sense of entitlement myself for all kinds of things, there is an element of “my generation is so much better and kids today suck” that’s, well, nostalgic indulgence and ignores every generations’ responsibilities (we didn’t get to here from there alone!). I’m part of what we call the “Gap Generation” – we’re not Boomers but we’re not Gen X either (I’m 44, we’re the punk rock generation). We bridge the gap between the pre-digital and the digital era (during our youth home computers came into use and the first video games were invented, hip hop and sampling emerged, video came into being and the list of how the world and communication changed goes on). We also saw Reagen be elected in the US rather than Carter (Carter was addressing environmental and oil-related issues, Reagen was starting wars and trying to get through the first draft of Homeland Security – what has come to political fruition both in terms of international conflict and US politics began in the 80s, or earlier) – if you think that the Neo-Cons have nothing to do with the attacks on reality-based thinking, you’re not thinking clearly!

    My generation got stuck with Boomers who see us as a threat to their jobs and who’d rather hire someone their kid’s age (total incompetence is entirely acceptable because it doesn’t challenge Boomer authority or show them up). And we got stuck with older generations who want the world to be like it was pre-digital and who have an industrial/manufacturing society mindset (and still resent feminism, any form of social equalizing, etc and like to to do the “when I was young we didn’t have bootstraps so I flayed my calves and pulled myself up by my own flesh!” thing almost as much as me and my friends my age like saying “back before the internet” to our younger friends and employees).

    The problems with overconsumption are based in The American DreamTM, which promises more of everything for everyone all the time. The American Dream is a marketing myth that Americans have taken on as a patriotic ideology (not that other wealthy countries don’t have their own version, they just tend to have more equalizing social systems and less rampant consumerism, still rampant but not like in the US). So the Boomers are finally waking up to the fact that someone pays for stuff (eventually or via starvation wages), limits exist (duh!), actions have consequences (duh!), isolation isn’t happiness and that they’re not actually happy (which they consider their birthright, as proscribed by The American DreamTM). Boomers are seeking faith but don’t want to take on their parents religion. Why? Because they’re “alternative” so they want an “alternative” religion, and mostly they’re just afraid of their mortality (my generation got to deal with AIDS, we’ve already dealt with mortality – quite personally and viscerally a lot of us).

    So, while it’s tempting to blame those older or younger than us – we’re ALL responsible for the state of the societies we live in (I’m pretty sure it wasn’t all Boomers who voted Bush Jr into office, or Senior for that matter – and these politicians have been instrumental in propping up car companies and stalling initiatives to deal with the energy crisis, global warming-or which the war in the middle east is a HUGE contributor, etc).

  27. Good heavens overshoot, please tell me it isn’t so! Please tell me you aren’t really saying that science has failed ME, that I am going to die someday and that there isn’t some inexpensive, safe natural product or therapy that I can buy and hopefully get a third party to pay for to prevent that from ever happening!

    Now wrinkle cream, I’m sure it sells well because it is always on the market, but is there even a correlation between its use and a decrease in wrinkles? I doubt it. If there were, who would have a facelift? I think things like wrinkle cream and baldness “cures” sell because many hope that the promises are true or simply deceive themselves into thinking that they see the results they want when any objective measurement would show that they are wrong.

  28. Fifi says:

    rjstan – “I think things like wrinkle cream and baldness “cures” sell because many hope that the promises are true or simply deceive themselves into thinking that they see the results they want when any objective measurement would show that they are wrong.”

    Too true and they’re hardly new products – people have been slathering themselves with toxic substances in an attempt to be more beautiful, youthful and/or virile forever (Narcissus’ story is hardly new!). Advertising is all about creating needs for unnecessary products as a means to keep the economy “bustling” – after all, we don’t really NEED much and most of what we need doesn’t actually come from factories.

  29. overshoot says:

    Fifi:

    FWIW and FYI, I’m a boomer whose boss is just over forty — and no question he’s at least as good a manager as any I’ve had. At the other end of things, I’m not the real voice in the family against the “entitlement mentality” in “kids these days.” That honor goes to my youngest, a just-turned-23 grad student.

    Back to topic, however, I posit that the rise of a market for woo can be traced to the rising awareness of boomers that they are no longer the young things that have dominated their self-images, and that reality isn’t promising them eternal youth on the beaches of Southern California.

  30. Fifi says:

    overshoot – Fair enough, I don’t personally blame any one generation (though obviously I’m rather cynical about many Boomers since their population bulge – the potbelly born of an over indulged sense of entitlement if you will! – has overshadowed my generation for decades). There are people of all generations who care more about having a heated leather car seat than the fact that their neighbor is starving – the gated community keeps in and out people of all ages! Seriously, I think the lie that America is a classless, egalitarian society and everyone has equal chance (The American DreamTM) – combined with advertising and consumer culture that constantly reinforces this “promise” – is really what’s behind the greed and stupidity. That and the ongoing destruction of decent public education in the US (which is another manifestation of the “I’ve got mine, screw you neighbor” mentality).

  31. Fifi says:

    I suspect that there are a number of things that contribute to the rise in woo – certainly there are Boomers trying to avoid aging, there are fears of mortality (apparently many Boomers haven’t had to deal with much death or don’t care unless it touches them personally), there’s a general fear about the destruction of the environment and chemical technology/industrial science (which manifests as a neurotic focus on “purity”, “cleansing”, supplements to replace food since food is demonized in various ways), and there’s a deep desire for a religious/spiritual framework to comfort them but they see themselves as “alternative” or “rebels” so few of them return to their parents’ church but want something that offers the comfort of religion while still being “hip” and “radical”. Throw in clever and MLM and very concerted efforts by the supplement industry and you end up where we are now. Personally I don’t think either nostalgia for the authority of The EstablishmentTM or the unrealistic Utopian technophilia of both the Boomers and Gen Y (and quite a few Gen Xers but Gen Xers at least have some Dystopian visions), will offer the solution since these mindsets helped get us here in the first place!

  32. I for one am glad it has taken this long for Weil to “integrate” 8 residences and Katz to get his program into Yale. Unscientific medicine has been working its way up from the back-to-nature, old hippies out in the woods into the mainstream marketplace and institutions that used to be scientific for many years now. It reached some of those institutions a long time ago.

    For a very good overview of the situation go to the NY Times archives and read:

    The Experiments of Dr. Oz
    By CHIP BROWN;
    Published: July 30, 1995

    In case I am ever incapacitated I think I’m going to add a clause to my Living Will stating that under no circumstances will I accept any treatment that is not backed by solid scientific evidence.

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