Quoth David Katz: Don't abandon patients. Abandon science instead.

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

A couple of weeks ago, I posted a short (for me) piece about something that disturbed both Steve Novella and myself, namely An herbal medicine clinic at the Cleveland Clinic: Quackademia triumphant Steve had blogged about it as well a couple of days earlier. To my surprise, Maithri Vengala over at The Healthcare Blog noticed the blog post and asked me if I would mind letting her post it over there. Never being one to turn down a request to showcase my work to a wider (or at least different) audience, I gave her my permission. The result was that my post also appeared here, and I thought nothing more of it.

Until yesterday, that is.

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

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

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

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

That's nice.

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

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

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

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

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

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

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

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

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

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

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

Or:

Or:

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

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

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

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

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

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

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

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

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

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

[...]

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

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

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

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

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

Particularly contradictory is this assertion:

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

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

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

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

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

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

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

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

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

Maybe he wouldn't have come to the conclusion that the only way he can help patients whom he can't cure is to abandon science in the guise of claiming to be scientific. It's a false dilemma that drives too many physicians to abandon their critical thinking skills as well. Indeed, David Katz is the very epitome of having a mind so open that his brains fall out.