Respectful Insolence

One of the claims most frequently made by “alternative medicine” advocates regarding why alt-med is supposedly superior (or at least equal) to “conventional” medicine and should not be dismissed, regardless of how scientifically improbably any individual alt-med modality may be, is that the treatments are highly “individualized.” In other words, the “entire patient” is taken into account with what is frequently referred to as a “holistic approach” that looks at “every aspect” of the patient, with the result that every patient requires a different treatment, sometimes even for the same disease. Indeed, as I have described before, a variant of this claim, often laden with meaningless pseudoscientific babble about “emergent systems,” is sometimes used to claim that the standard methods of science- and evidence-based medicine are not appropriate to studying the efficacy of alternative medicine. I’ve dealt with this latter argument before in considerably detail, but I want to revisit it in the context of looking at the “personalization” of treatments that alternative medicine practitioners tout as perhaps the greatest strength of their approach.

I was surprised to learn that even some advocates of alt-med have their doubts that it is such a great strength. Indeed, I never realized that this might have been the case until I came across a post by Travis Elliott, who runs a pro-alt-med blog, Dr. Travis Elliott and the Two-Sided Coin entitled The Single Most Frustrating Thing About (Most) Alternative Medicine. In this article, he referred to a case written up by a fellow naturopath, who used an anecdote the evaluation and treatment plan by a naturopath of a pregnant woman with nausea to show what is supposedly the “unique power of our medicine.” Oddly enough, Elliott did not quite see it that way:

The physician who wrote the article is a chiropractor and naturopath whose practice is nearly 100% musculoskeletal issues. He said that he nearly always refers patients out for other issues, but this case was a woman who requested that he treat her pregnancy-related nausea.

This physician tried, in a series of appointments: ginger root, rasberry tea, pre-natal vitamins, a blood-type diet, acupuncture, acupressure, and spinal manipulation. None of these treatments worked, but the patient persevered.

Finally, the physician reached further in to his toolbox and prescribed a homeopathic remedy that cured her on the spot. The physician noted, “we are so fortunate as naturopathic physicians to be trained in many modalities. … This case reminded me that [we can treat on a much more personalized level] when we are equipped with so many different tools.”

By coincidence, this very aspect of alternative medicine was brought up with not so glowing a description last week during my 2007 update of You Might Be an Altie If…, where item #80 states:

If you try bazillions of cures until symptoms go away, then declare the last one to be a cure, you might be an altie.

Which is most likely what happened in the case described, particularly since the last “remedy” tried was homeopathy, arguably the most utterly ridiculous and scientifically implausibly risible “treatment” ever conceived by a human mind. Most likely, what happened is that this patient’s symptoms regressed to the mean, and this regression to the mean happened to correspond with the trial of a homeopathic remedy. Be that as it may, however, Elliott brings up an interesting point, one that I’ve never heard an alt-med advocate bring up before:

This case can certainly be hailed as a success, since the patient was healed and no harm was done by the initial treatments that didn’t work. But I can’t help but feel badly for the woman for having to go through so much trial and error to get results. I mean, it probably cost a significant amount of money to keep returning to this physician for his next guess.

This is exactly the kind of situation that frustrated me when I practiced naturopathic medicine. How did I know what would work for a patient? (I didn’t.) And just like this physician, I didn’t think that there was any way to know, either. I could try and learn from each patient and apply that knowledge to the next one with similar symptoms, but each patient was so unique that what cured one person might have no effect on the next.

Meanwhile, patients are forced to try treatment after treatment, doctor after doctor in search of a solution that works.

Of course, I can’t help but marvel at the irony here. If such a patient went to a conventional doctor (or to multiple conventional doctors) with a complaint of nausea, and various remedies were tried and didn’t work, just imagine the reaction of alties to that. This same case, if it had been handled by “conventional medicine” would be cited by alternative medicine aficionados as “evidence” of how ineffective “conventional medicine” is! Indeed, how many times have you heard “testimonials” that begin with a patient describing a trek from doctor to doctor, all of whom were unable to diagnose the problem or find an adequate treatment? I can just hear it now: The sarcastic commentary about how poorly conventional medicine does with problems such as nausea in pregnancy and how superior “alternative medicine” is in dealing with such complaints. Yet, here we have a case being presented in which the patient was forced to try remedy after remedy, none of which worked until the end, where it is not clear whether the “homeopathic” remedy actually did anything (chances are that it did not) or the nausea simply regressed on its own thanks to the tincture of time. And this case is presented as a success! Now that I think about it, hanging around the alt-med Usenet newsgroups years ago, I heard similar stories time and time again. If you lurk on the CureZone message boards, you’ll find hardcore alties discussing trying various remedy after remedy, touting some and dissing others, all on the basis of little or no evidence.

After praising some sort of alternative medicine diagnostic modality called the BodyTalk system, which, supposedly greatly decreases this extensive “trial and error” approach, Elliott concludes:

Two years ago, I would have wholeheartedly agreed this case of nausea was a great success. But now that I know better, I see it as another sign of how far alternative medicine needs to go.

Yes, “individualization” of treatments is touted as the greatest strength of alternative medicine. Indeed, if you look at the UCSF alternative medicine manual that I blogged about previously, you will see in the descriptions of various modalities the emphasis on “individualization.” Who can argue that this is a wonderful thing?

I can, at least to a point.

Here’s the problem with “individualized” treatments. Taken to an extreme, as many alternative medicine practitioners do, it’s in essence an excuse not to have to list diagnostic criteria or show actual efficacy of their treatments in a way that others can replicate. Look at Dr. Elliott’s statement: “Each patient was so unique that what cured one person might have no effect on the next.” Certainly, biological organisms such as humans can and do show considerable variability in their biology and response to treatment, but not so much that what “cures” one person will have no effect on the next. Similarly, such extreme emphasis of “individualization” leads to exactly the sort of marathon trial-and-error treatment histories he described.

Let’s compare and contrast. In “alternative medicine,” it is very frequent that consultations by different practitioners for the same patient with the same symptoms will result in completely different diagnoses and courses of treatment. In contrast, although there can certainly be disagreement among conventional doctors about the diagnosis and/or treatment for an individual, such disagreements tend to occur within a much narrower range of possibilities. That is because they will have more standardized diagnostic criteria based on data, rather than the individual idiosyncrasies and beliefs of different practitioners. In essence, evidence-based medicine, through clinical trials and research, has done a lot of the trial-and-error work already, so that individual practitioners don’t have to, resulting in protocols that work for a majority of patients. When those protocols do not produce the desired results, then the choices for “individualization” of therapy are much narrower and based on science and evidence gleaned from clinical trials of large numbers of patients. (Yes, one danger is that this can devolve into “cookbook medicine,” but in reality, as long as the protocols are not too rigid, the good of such protocol-based medicine likely outweighs the bad.) In alt-med, however, what is tried first depends almost entirely on the individual practitioner, as does what is tried next–and next and next and next. There is no standardization and no scientific basis on which to choose treatments.

This emphasis on “individualization” in alternative medicine is particularly ironic when we consider certain specific alternative medicine practitioners, in whose practice disease causation all too often devolves into ludicrous commonalities in which there is claimed to be a single cause for many diseases. For example, Hulda Clark claims that “all cancer” is caused by intestinal flukes and that “the cure for all cancers” is in essence the same for everyone, a degree of standardization that even the most dogmatic practitioners of evidence-based medicine would find hard to swallow. After all, none of us would ever claim that “all cancer” has a single cause. Similarly, she claims to have the cure for AIDS based on similar principles, even though the causes of AIDS and various cancers are clearly different. Meanwhile Reiki therapy, acupuncture, and a wide variety of other alternative medicine modalities claim that all disease is due to an “imbalance” in your life energy (qi) or a blockage in the flow of qi that needs to be eliminated; the only way that the differ is in the methods that they use to alter the flow of qi in order to cure. Or consider the case of the frequent alt-med claim that some therapy or other “boosts the immune system,” as if that were always a good thing and there were no such things as autoimmune disorders due to the excessive or in appropriate activation of the immune system.

In the end, this fetish for “individualization” in alternative medicine is a sham. It’s invoked when it is convenient to do so, particularly in the cases of “treatments” like homeopathy, in which any therapeutic effect perceived is due to the placebo effect. However, if you think about it, many alternative medicine modalities are far more rigid than conventional medicine in ascribing a specific cause to disease. When you come right down to it, the emphasis of alt-med on “individualization” and “treating the whole person” consists of little more than marketing buzzwords. There’s no evidence that alt-med does any better at treating the “whole patient” than conventional medicine and considerable evidence that, by lumping many diseases of unrelated pathophysiology together and using the same treatments for them, alternative medicine’s claims of “individualization” means the freedom to keep trying stuff until the patient’s symptoms get better on their own.

Comments

  1. #1 Ruth
    March 5, 2007

    Most nausea clears up on its own by month 3 or 4. Just an example of a cold lasts a week without treatment and 7 days with treatment.

  2. #2 anonimouse
    March 5, 2007

    “Individualization” is an easy way for alt-med practitioners to say that their nonsense can’t be tested. It’s the card they play when someone asks them for double-blind studies or other sensible research regarding their alleged treatments.

  3. #3 Robin Peters
    March 5, 2007

    Yes, it is almost impossible to replicate the alt-med stuff precisely because they claim it’s individualizzed. But I submit that this is precisely its attraction to patients – the reason why so many people like me visit them. We want to be treated as individuals, not according to a strict, seemingly unfeeling protocol that isn’t flexible or designed to meet our unique needs. Whether we like the idea or not, many people in conventional medicine treat us this way.

    Don’t get me wrong. Most of the treatment I’ve received at the hands of the conventional guys has been excellent. But I have been burned by protocol-based medicine which didn’t allow for perhaps the fact that I might have been allergic to a drug. According to a protocol-based practitioner, you get a drug anyway just because it’s on the protocol, even if it’s ineffective or you’re allergic to it. The time I was burned by such medicine (metaphorically speaking, of course), it was because the attendings were simply too lazy to do adequate followup, and the interns and residents were too inexperienced to know they were looking at ineffective methods (or perhaps an allergic reaction).

  4. #4 anonimouse
    March 5, 2007

    According to a protocol-based practitioner, you get a drug anyway just because it’s on the protocol, even if it’s ineffective or you’re allergic to it.

    I don’t believe that. If you disclose to your doctor that you’re allergic to a particular medication, I can’t imagine they’d just say “oh well, tough, you have to take it anyway, enjoy the anaphylaxis”. There may be instances where a doctor incorrectly prescribes a drug or doesn’t consider possible sensitivities, but that’s the exception rather than the rule.

    And besides, you are far more likely in the long run to have an issue with herbal treatments (where what’s on the bottle might not be actually what’s in the treatment) than with tightly regulated pharmaceuticals. I’d be much more scared of taking some unknown supplement than a licensed drug I can read up about online and have a reasonable assurance that it is what it says it is.

  5. #5 bob koepp
    March 5, 2007

    The notion that “individualized” medicine is not amenable to rigorous scientific testing won’t stand up to scrutiny. That’s a good thing, because pharmacogenetics is all about tailoring treatments to individuals.

  6. #6 Teresa Michelsen
    March 5, 2007

    Thanks to the previous commenter for pointing out what I wanted to – I hope that “western” medicine goes more in the direction it seems to be of individualizing its approach. By this I mean recognizing that different doses are appropriate depending on weight, diet, age; pharmacogenetics, and other issues such as treatments for chronic problems that do vary greatly by individual.

    I have chronic migraines and these do tend to be very individualized – what works for one person does not work for another. There are many things that cause them – some are hormone-based, some are diet, some have mainly environmental causes. Western doctors need to be flexible in trying out different treatments until the best one is found for the patient, rather than insisting on a rigid protocol. And sometimes the best treatment is a mix of western and “alternative” medicine, especially when backed up by clinical trials.

    What works best for me right now is a seizure medication, backed up by large doses of B2, and hormonal regulation using continuous birth control pills. All this is through the advice of my neurologist and we have found through careful experimentation that each of these three components is necessary and helpful, even though one is “western”, one is “alternative” and one is a use of a western medicine that is unusual but logical.

    It bugs me when I see black-and-white characterizations of the issue on either side, since what those of us with serious problems need is more open-mindedness toward various solutions coupled with rigorous experimentation.

  7. #7 KeithB
    March 5, 2007

    Of course, evidence based medicine is working towards this goal, too. I can think of two examples:
    You are always tested before given horse serum to prove you are not allergic.

    The new blood pressure drug that was found to work best in african americans.

  8. #8 Bronze Dog
    March 5, 2007

    It bugs me when I see black-and-white characterizations of the issue on either side, since what those of us with serious problems need is more open-mindedness toward various solutions coupled with rigorous experimentation.

    Truth is black and white: Statement are either true or false. Alties have a habit of making demonstrably false statements, or making statements and excuses not to check them.

    As for open-mindedness, get some alternative medicine that passes rigorous clinical trials, and we’ll drop the “alternative”. What do you call alternative medicine that works? Medicine.

    Definitely in favor of more pharmacogenetics research, here.

  9. #9 Sid Schwab
    March 5, 2007

    I just came up with the name for a new therapeutic approach: “miuayga.” It has a sort of Asian feel, and I’m guessing it would therefore be highly marketable among alties. And the beauty is it can encompass pretty much whatever you want. Just don’t tell anyone what it stands for: “make it up as you go along.”

  10. #10 Joe
    March 5, 2007

    @Robin P, The notion of “individualized therapy” is meaningless if the “therapy” is worthless. It is akin to having a custom astrology chart instead of the generic one in the newspaper; both are nonsense.

    @anonimouse, I hope I haven’t plugged this here before- there is a great book by Dan Hurley “Natural Causes” (Broadway Books, 2006) that describes the hazards of herbs and “supplements.” The label can be quite spectacularly wrong, as when people thought they were taking stephania; but got aristolochia, instead (which is known to cause kidney failure and cancer, and it did).

  11. #11 Zebee
    March 5, 2007

    Maybe some doctors are a bit too much into “the average patient”. http://www.abc.net.au/rn/healthreport/stories/2007/1854032.htm (podcast and transcript) is about a scientist who refused to be treated to a statistical average, because *his* scientific training made him think there was no such thing as the average patient and that the way his doctors made decisions was flawed. It’s not the same individualisation as the alties, but it’s a different look at just what evidence based is in action.

  12. #12 Davis
    March 5, 2007

    I don’t understand why the “individualized” altie approach should be immune to double-blind testing. I can easily imagine such a trial — for example, 50% of patients seeing a homeopath could be given ordinary water instead of the prescribed “special” water. On the one hand, you don’t get to test any specific treatment; on the other hand, you do get to test the general efficacy of homeopathy.

    Actually, this sounds vaguely familiar — have any studies employed such a technique?

  13. #13 Joe
    March 5, 2007

    @Davis, It is hard to understand; but the alties always have two outs: 1) I did not choose the correct, individual treatment; and 2) the person came to me too late for my therapy to work.

    The alties say no two conditions are alike. Therefore, one can’t assemble 1,000 people with the same “medical” condition for a major clinical trial. It may be clear to you that you can find 1,000 people with cholecystitis; but the altie sees a wide variety of “problems” in that population.

  14. #14 Liz
    March 5, 2007

    A step back perhaps: Is alt med. in fact individualized treatment?

    It’s possible some physician-proponents of entrenched alt med. interventions including chelation therapy, nonsensical allergy interventions, IV H202, and cancer “stuff” provide precisely the opposite of individualized care – despite vociferously defending their actions on this basis.

    After you’ve read about a hundred statements of charges and medical board orders, patterns emerge. These licensees couldn’t have provided individualized care if they didn’t examine patients, take medical histories, or record squat’s worth of information in the chart. Individualized treatment in the face of a blank or nearly blank chart is a non-starter.

    When there is a diagnosis, it’s often “presumptive” and yet to be confirmed, even years later. Patients in a single practice appear to have have the same diagnosis or constellation of “things.”

    “Treatment” works out to most or all patients getting chelation therapy (metal toxicities), Corticef (adrenal fatigue), sublingual allergy drops, Nystatin or (god help us) Amphotericin B (candida), thyroid hormone, and testosterone (both men and women) or bioidentical hormones.

    This would be merely stupid and wasteful if it weren’t for the fact that some patients have serious diagnoses that weren’t treated or didn’t benefit from massive unjustified overtreatment. Put differently, unlike the happy pregnant woman, some patients don’t stop vomiting.

    If the alt med. boys and girls use chelation or “fill in the blank” to treat to cancer, heart disease, impotence, Gulf War Syndrome, autism, Alzheimer’s, and “general wellness” in 100 patients, have they provided individualized intervention to 100 patients with different disorders and conditions, or have they provided the same invention(s) to 100 patients with different disorders and conditions?

    We accuse physicians of over-reliance on treatment algorithms and guidelines to force the same treatment on patients diagnosed with X or Y, yet on closer inspection it seems some/many alt med. practitioners described in medical board orders provide the same intervention(s) not only to patients with X but to patients with X, and A – W.

    If they defend deviation from the standard of care in intervention on the basis of patient individuality, why do they use the same damn thing on so many patients?

    If alt med. is individualized why is it subject to fads? Mesotherapy? Orthomolecular whatever? HGH? H202? Misbranded TENS devices NOS?

    So why can’t we be more tolerant … Because we know the history, or should do. At the risk of abusing the memory of an innocent child, we knew that Endrate chelation therapy per the protocol published by chelationists was the cause of death of at least fourteen patients at Meadowbrook Hospital in the early 1970s:
    http://www.circare.org/tact/17-1790_19760928.pdf

    We know Endrate causes serious adverse reactions, and we can point to cases of injury and death before and after 1975. Yet alt med. in its peculiar blindness continues to promote Endrate and an autistic child dies a quarter century later.

    As for academic medicine, well … let me leave you with the cheery thought that a well-known PI referred to an unpublished “summary” of chelation therapy results writen by the physician who was enjoined by the feds after the deaths at his Meadowbrook Hospital – above. In the drug safety section of an NIH grant application.

    Bedtime reading for those who don’t want to sleep – board orders etc.
    Quackwatch:
    http://www.casewatch.org/board/med/boardindex.shtml
    and
    http://www.quackwatch.org/11Ind/index.html

    CIRCARE:
    http://www.circare.org/pd/physicians.htm

    Liz

  15. #15 Kelly
    March 5, 2007

    For legitimate medical conditions, the chances of untested treatment X working for a person are nada or indeterminate at best.

    I think alt medicine may have a place with many of the people that cruise through my ER 4 or 5 times a month with psychosomatic complaints though. Sure, it’s a placebo effect, but the “disease” is only in their head too, so, in theory, it sounds like it would work. A “cure” for a disease that never existed in the first place ;-).

  16. #16 Justin Moretti
    March 5, 2007

    What is interesting is that he touts “wisdom-based health care in a world dominated by knowledge.”

    I hope anyone coming across his blog realizes just how ludicrous this statement is.

  17. #17 Renee
    March 5, 2007

    If a person has a common condition, and they are close enough to the average patient, then they’ll very likely get effective treatments with conventional medicine. They are unlikely to need individualized treatments.

    It’s when a person has an uncommon condition, for which there are few agreed-upon or effective treatments, that things get dicey. It’s going to take more time and attention from a doctor to figure out what exactly the diagnosis is, and what treatments to try.

    The problem is that doctors nowadays don’t have time. Just read a couple of medical blogs, and it’s clear that due to economic pressures from various sources, they cannot spend more than 10-15 min. per patient.

    It’s not that I don’t sympathize with doctors with all the pressures they’re under. My impression is that even if a doctor wanted to give more individualized attention to a patient, they simply cannot because they cannot afford to do so.

  18. #18 bcpmoon
    March 6, 2007

    So individualization simply means being a guinea pig? And each time I visit my altie doctor he has to start again from scratch because my birthstar is aligned with some other planet? Great.
    Visiting an altie practitioner will surely help you, the placebo effect sees to that. And of course a double blind testing is easy, see Davis´ comment. Alties are ultimately selfish, either they are in it just for the money or they need the psychological benefit of being the good samaritian.

  19. #19 Prometheus
    March 6, 2007

    “Individualized treatment” sounds very hip and caring, except when you stop to figure out what it really means (as in this excellent post). What does “individualized treatment” mean in “alt-med” land:

    Trying treatment after treatment until one works.

    How is this different from what a real doctor does? If the first treatment doesn’t work, don’t they usually move on to either a different dose or a different medication?

    The difference, from my perspective, is that real medicine has some scientific data to support the choices the real doctors are making – not always extensive or iron-clad data, but data.

    “Alternative” medicine, on the other hand, makes fad-based diagnoses (based on whatever are the hottest new pseudo-diagnoses on the street) and “treats” them with a seemingly random selection of whatever happens to be on the shelf. Naturopathy, vitamins, fad diet therapy, acupuncture, acupressure chiropractic and finally homeopathy. What a wide range of woo!

    It seems that “alternative” medicine is emphasizing “individualized treatment”, but that the “individual” who is being accomodated is the practitioner! Is there any evidence that this naturopath/chiropractor/homoeopath had a clue about what he was doing, or was it all a random-walk through the “alternative” medicine armamentarium?

    Prometheus.

  20. #20 mark
    March 6, 2007

    Reminds me of a local water-supply manager, bragging about the wonderful well his hired dowser picked a spot for. When asked about all the drill cuttings lying about that indicated numerous wells were drilled, he answered that yes, the dowser picked a number of spots that turned out to be dry holes, but when he picked the good spot to drill, it was a good spot! It also was the last well drilled.

  21. #21 Antiquated Tory
    March 8, 2007

    My very first Med Anth prof had done his field work among the Amara of Ethiopia. They have a ‘black box’ idea of how the human body works, so no drugs, surgery etc. Everything done was done very ‘holistically,’ that is to the person rather than any part thereof.
    Their treatment for rabies was very simple: If someone is bitten by an animal, he is thrown into a stream or other running water. Observation shows that about 90% of these patients do not develop rabies! The Amara are not dumb; if most bitten people developed rabies, they would not believe in the therapy. Of course, only about 10% of animal bites in that area lead to rabies, anyway…
    Unfortunately, the Amara have what is called a ‘hierarchical’ (as opposed to ‘parallel’) use of medical practitioners, meaning that they always try a certain choice first, then move to the next choice, then the next and so on. Sadly, getting to the district clinic is invariably the last choice. By the time someone who has contracted rabies gets to an actual physician, the disease has progressed too far to be cured, and the patient dies. So the Western practitioner has a 0% efficacy rate!

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